Coagulation versus excision of primary superficial endometriosis: a 2-year follow-up

Objective

Even the common mild forms of endometriosis can strongly affect quality of life due to dysmenorrhea, dyspareunia, dyschezia, or subfertility. We compared the effectiveness of the two laparoscopic methods, coagulation versus excision, for intraperitoneal superficial endometriosis with regard to recurrence and symptom control.

Study design

In a retrospective analysis we evaluated the postoperative follow-up of 79 patients, aged 16–42, with superficial manifestation of endometriosis (median rASRM score 9.2) operated on in the Department of Gynecology and Obstetrics at the Jena University Hospital. Forty-three patients were treated by electrocoagulation and 36 underwent sharp excision. Therapy success was evaluated by using a questionnaire after a mean follow-up of 29 months. Patients were interviewed about pain associated with endometriosis such as dysmenorrhea, dyspareunia, dyschezia and possible medical treatment after surgery. We evaluated the number of surgically proven relapses and questionnaire results using a pain score on an ordinal scale (1–5) for the three categories dysmenorrhea, dyspareunia, and dyschezia.

Results

Both treatment methods resulted in a low number of endometriosis-related symptoms after surgical intervention and in recurrences of 2.8% in the coagulation group and 18.6% in the excision group. The recurrence rate in the coagulation group was lower (p = 0.001). The coagulation group was also presented with a significantly lower postoperative pain score at our long-term follow-up (p = 0.0067).

Conclusion

In cases of superficial endometriosis, laparoscopic surgery achieved low recurrence rates and good symptom control. Compared to sharp excision the use of bipolar electrocoagulation might result in fewer endometriosis-related symptoms as well as fewer relapses with need for surgical re-intervention after a more than 2-year interval. Due to the retrospective, non-randomized character of this study the results should be interpreted carefully. Further prospective studies are needed to assess the value of both surgical approaches in the treatment of endometriosis.     

The adjuvant use of N-palmitoylethanolamine and transpolydatin in the treatment of endometriotic pain

Objective

To test the adjuvant use of the combination of N-palmitoylethanolamine and transpolydatin in the medical treatment of endometriotic pain.

Study design

We enrolled 47 patients admitted to the Outpatient Endometriosis Care Unit of Ferrara University from January 2011 to December 2011. They were divided into two groups according to the endometriosis site (group A: recto-vaginal septum; group B: ovary). One tablet, containing 400 mg of micronized N-palmitoylethanolamine plus 40 mg transpolydatin, was administered twice daily on a full stomach for 90 days. Each patient was requested to grade the severity of dysmenorrhea, chronic pelvic pain, dyspareunia and dyschezia using a 0–10 cm visual analogic scale prior to beginning treatment (T0), after 30 days (T1), 60 days (T2) and 90 days (T3). The continuous and categorical variables were compared, respectively, using Student's t-test and the chi-square test. Analysis of variance for repeated measures was used to verify the reduction of endometriotic pain.

Results

The intensity of endometriotic pain decreased significantly for both groups (p < 0.0001). The efficacy of drug treatment was significant after 30 days. Pain intensity decreased equally in the two groups except for dysmenorrhea, which was reduced more rapidly in group B.

Conclusions

The combination of N-palmitoylethanolamine and transpolydatin reduced pain related to endometriosis irrespective of lesion site. It had a marked effect on chronic pelvic pain determined by deep endometriosis and on dysmenorrhea correlated to ovarian endometriosis.     

The impact of IVF procedures on endometriosis recurrence

Objective

In infertile women with endometriosis requiring an in vitro fertilization (IVF) procedure, the potential risk of an IVF-related progression of the disease remains a matter of debate. Thus, since available data on this issue are scanty and controversial, an observational study has been herein conducted in order to clarify this issue.

Study design

We recruited 233 women with endometriosis who underwent IVF cycles in our unit. Patients were contacted to assess whether they experienced recurrences of the disease after IVF. The main outcome was to evaluate the impact of the number of IVF cycles and the responsiveness to ovarian hyperstimulation on the likelihood of recurrence. Clinical characteristics of women who did and did not have a recurrence were compared.

Results

One hundred and eighty-nine women were included, 41 of whom (22%) had a diagnosis of endometriosis recurrence. The 36 months cumulative recurrence rate was 20%. The number of IVF cycles and the responsiveness to ovarian hyperstimulation were not associated with the risk of disease recurrence. The adjusted OR for recurrences according to the number of started cycles was 0.92 (95% CI: 0.77–1.10) per cycle (p = 0.35). The adjusted OR for recurrences in women with intact versus compromised ovarian reserve was 0.80 (95% CI: 0.40–1.58) (p = 0.52).

Conclusions

IVF procedures do not seem to influence the likelihood of endometriosis recurrence.     

Biopsychosocial correlates of persistent postsurgical pain in women with endometriosis

Objective

To examine pain and biopsychosocial correlates over time for women with persistent postsurgical pain after surgery for endometriosis.

Methods

Cross-sectional study of women who underwent any endometriosis surgery between 2003 and 2006. Following surgery, patients completed validated questionnaires (Short-Form McGill Pain Questionnaire, 12-item Short-Form Health Survey, Beck Depression Inventory, Coping Strategies Questionnaire catastrophizing subscale). The primary outcome was pelvic pain intensity, measured by the McGill total pain score. Bivariate comparisons between each potential predictor and pain intensity were performed using the χ² and t tests, 1-way analysis of variance, and simple linear regression.

Results

In total, 79 completed the questionnaires and were included in the present analysis. The McGill affective pain score was negatively correlated with age (β-coefficient –0.12, P = 0.002) and positively correlated with catastrophization (β-coefficient 0.66, P = 0.01). Women with a history of dyspareunia scored significantly higher on the McGill total pain score (P < 0.001); there was no association between pain intensity and endometriosis severity.

Conclusion

Younger age and catastrophization are correlated with persistent pain following surgery for endometriosis. The severity of endometriosis does not predict persistent pain. Further evaluation of psychosocial factors may identify patients who are least likely to benefit from surgeries for endometriosis-associated pelvic pain.     

Hiperplasia ductal atípica de mama: correlación de la biopsia percutánea y los resultados de la biopsia quirúrgica

Objetive

The purpose was to evaluate the prevalence of carcinoma found at surgical biopsy of llesions identified as atypical ductal hyperplasia by percutaneous breast biopsy.

Methods

We performed a retrospective study of all asymptomatic patients with a result of atypical ductal hyperplasia on percutaneous breast biopsy and who underwent surgical excision from January 2002 to December 2010.

Results

Sixty-eight patients were found to have atypical ductal hyperplasia at percutaneous breast biopsy and were evaluated with surgical biopsy. Seventeen patients (25%) had carcinoma at surgical excision, 10 had ductal carcinoma in situ, and 7 patients had invasive carcinoma. The mammographic characteristics associated with malignancy were analyzed.

Conclusions

A finding of atypical ductal hyperplasia at percutaneous breast biopsy frequently corresponds to cancer and is therefore an indication for surgical excision.     

The influence of endometriosis-related symptoms on work life and work ability: a study of Danish endometriosis patients in employment

Objective

Little is known about the implications of endometriosis on women's work life. This study aimed at examining the relation between endometriosis-related symptoms and work ability in employed women with endometriosis.

Study design

In a cohort study, 610 patients with diagnosed endometriosis and 751 reference women completed an electronic survey based on the Endometriosis Health Profile 30-questionnaire and the Work Ability Index (short form). Percentages were reported for all data. Binary and multivariate logistic regression analyses were used to assess risk factors for low work ability. The level of statistical significance was set at p < 0.025 in all analyses.

Results

In binary analyses a diagnosis of endometriosis was associated with more sick days, work disturbances due to symptoms, lower work ability and a wide number of other implications on work life in employed women. Moreover, a higher pain level and degree of symptoms were associated with low work ability. Full regression analysis indicated that tiredness, frequent pain, a higher daily pain level, a higher number of sick days and feeling depressed at work were associated with low work ability. A long delay from symptom onset to diagnosis was associated with low work ability.

Conclusions

These data indicate a severe impact of endometriosis on the work ability of employed women with endometriosis and add to the evidence that this disease represents a significant socio-economic burden.     

The occurrence of endometriosis with ovarian carcinomas is not purely coincidental

Objective

To explore the association between epithelial ovarian cancer (EOC) and common benign gynecological disorders.

Study design

The medical records of 226 patients with EOC treated at Peking Union Medical College Hospital between March 2011 and March 2012 were reviewed. Histological evaluations had been performed to determine the presence of coexisting pelvic endometriosis (n = 17), uterine leiomyoma (n = 66), adenomyosis (n = 22), or endometrial polyps (n = 17).

Results

Coexistence of endometriosis occurred in 35.3% and 36.4% of cases of the clear cell and endometrioid subtypes of EOC histology, respectively. Endometriosis was more likely associated with clear cell or endometrioid ovarian carcinoma, but less likely with high grade serous cancer. No differences were observed in the concurrence of uterine myoma, adenomyosis or endometrial polyps among the different subtypes of EOC.

Conclusions

In contrast to other common benign gynecological disorders, endometriosis showed close relationships with the clear cell and endometrioid subtypes of EOC specifically.     

Pronóstico y resultados en pacientes diagnosticadas de endometriosis a las que se les ha realizado por primera vez una cirugía conservadora por dolor o esterilidad

Objective

To analyze clinical outcomes in patients with suspected endometriosis undergoing conservative surgery. Pain reduction, pregnancy rates, and reinterventions were analyzed.

Material and methods

Patients with suspected endometriosis and symptoms of pain or infertility undergoing conservative surgery for the first time were included (n = 128). Exclusion criteria consisted of incomplete medical histories and interventions indicated for reasons other than pain or infertility.

Results

Surgery was indicated for pain in 70.3% and for infertility in 29.7%. A total of 32.5% of the patients had pain at the first postsurgical visit, 42.5% at 6 months and 58.3% at 1 year. Reintervention was performed in 11.29%. Among reinterventions for pain, there was a higher percentage of intestinal symptoms before surgery (P=.07), as well as episodes of abdominal pain requiring hospital care (P=.08); a higher proportion of these patients had pain in the first visit (P=.05) and at 1 year (P=.03) than patients not undergoing reintervention. Postsurgical medical treatment was less frequent in patients undergoing reintervention (P=.11). Among patients undergoing surgery for infertility, pregnancy was achieved in 65.8%.

Conclusions

Pain was less frequent in the first postsurgical visit than in subsequent visits. Among patients undergoing reintervention for pain, there was a higher percentage of intestinal symptoms and episodes of abdominal pain requiring hospital care prior to the intervention. Pain at the first visit and at 1 year are factors of poor prognosis for reintervention. Patients undergoing reintervention for pain less frequently required postsurgical medical treatment. More than half of patients with interfertility and endometriosis achieved spontaneous pregnancy after surgery.     

Effect of palmitoylethanolamide–polydatin combination on chronic pelvic pain associated with endometriosis: Preliminary observations

Objective

Endometriosis is a chronic oestrogen-dependent gynaecological disorder, the most common symptom of which is pain. Inflammation can be considered one of the major causes of pain in endometriosis. In particular, degranulating mast cells have been found in significantly greater quantities in endometriotic lesions than in unaffected tissues. The increase in activated and degranulating mast cells is closely associated with nerve structures in painful endometriotic lesions. These observations indicate that inflammation due to mast cells may contribute to the development of pain and hyperalgesia in endometriosis. Controlling mast-cell activation may therefore relieve the pain associated with endometriotic lesions.

Study design

Four patients presenting an endometriosis-related pain intensity ≥5 (visual analogue scale for pain, or VAS) were enrolled and monitored during 3 months of the following treatment: oral palmitoylethanolamide 400 mg and polydatin 40 mg, twice daily for 90 days. Deep dyspareunia, dyschezia, dysuria, dysmenorrhoea and analgesic drug use during the 3-month follow-up period were also monitored, with the aim of demonstrating a reliable reduction in chronic pelvic pain.

Results

The preliminary results indicate that all patients enrolled experienced pain relief as early as 1 month after starting treatment. Furthermore, a reduction in the analgesic drugs usually employed for pain control was observed in all subjects treated. Additionally, some improvements in endometriotic lesions seemed to be demonstrated by imaging.

Conclusions

The palmitoylethanolamide–polydatin combination seems to be very useful in controlling chronic pelvic pain associated with endometriosis. As a result of these findings we have initiated a multi-centre pilot study to verify the effectiveness of this treatment in controlling the chronic pelvic pain associated with endometriosis.     

Biopsia mamaria asistida por vacío y guiada por estereotaxia. Correlación con la biopsia quirúrgica

Objective

To evaluate the efficiency of stereotactic vacuum-assisted core breast biopsy as an alternative to diagnostic surgical biopsy.

Material and methods

A retrospective study based on 250 stereotactic vacuum-assisted percutaneous biopsies was conducted from March 2006 to August 2010. The false-negative rate and underestimation of disease at percutaneous biopsy were determined in comparison with diagnostic surgical biopsy.

Results

The false-negative rate was 2% (1/63) and the positive predictive value was 100%. Surgical excision revealed carcinoma in 30% (3/10) of the patients with atypical ductal hyperplasia at core biopsy and in 33.3% (2/6) of those with lobular carcinoma in situ. Among 40 lesions diagnosed as ductal carcinoma in situ at vacuum-assisted biopsy, surgery revealed invasive carcinoma in four (10%).

Conclusions

Stereotactic core breast biopsy can be considered a valid alternative to diagnostic surgical biopsy, although diagnostic underestimation still occurs.     

Polymorphic variants of DNMT3A and the risk of endometriosis

Objective

Overexpression of DNA methyltransferase 3A (DNMT3A) and aberrant methylation of various genes in eutopic endometrium have been demonstrated in women with endometriosis. We aimed to study whether DNMT3A polymorphisms could be a genetic risk factor for endometriosis and endometriosis-related infertility.

Study design

We studied 5 SNPs (rs2289195, rs7590760, rs13401241, rs749131 and rs1550117) located in the DNMT3A gene in 357 women with endometriosis and 640 controls.

Results

We did not observe significant differences between genotype and allele frequencies of rs2289195, rs7590760, rs13401241, rs749131 and rs1550117 SNPs in women with endometriosis, endometriosis-related infertility, and controls. The lowest p values of the trend test were observed for DNMT3A rs1550117 in endometriosis and endometriosis-related infertility (p_trend = 0.049 and p_trend = 0.055, respectively).

Conclusions

Our results did not supply evidence for the contribution of SNPs located in DNMT3A to either endometriosis or endometriosis-related infertility.     

Plasminogen activator inhibitor-1 4G/5G polymorphism and susceptibility to endometriosis in the Italian population

Objectives

Some controversy exists for the potential association of the plasminogen activator inhibitor-1 (PAI-1) gene polymorphism 4G/5G and susceptibility to endometriosis. To clarify this issue, we have examined the prevalence of this polymorphism in a case–control study in the Italian population.

Study design

The PAI-1 4G/5G polymorphism was evaluated in n = 368 reproductive year aged Caucasian women who underwent gynaecological laparoscopy for chronic pelvic pain, infertility, ovarian cysts and myomas. A second group of controls included n = 329 normal subjects.

Results

The 697 women enrolled were divided as follows: the endometriosis group (n = 204), the gynaecological control group (n = 164) and the general population control group (n = 329). No statistical significant differences emerged between endometriosis patients and gynaecological controls with regard to the allele frequencies and co-dominant and dominant models of genotype distribution. A borderline statistical difference was only observed for the recessive model of inheritance in which, contrary to previous findings, the PAI-1 4G/4G genotype seems to be less linked to the disease development.

Conclusion

The findings reported herein do not support the previously reported data indicating a greater susceptibility to endometriosis in patients harbouring the PAI-1 4G/5G and 4G/4G genotypes and exclude a significant role of polymorphism in endometriosis development.     

Factors Associated with Increased Pain in Primary Dysmenorrhea: Analysis Using a Multivariate Ordered Logistic Regression Model

Study Objective

In the literature about primary dysmenorrhea (PD), either a pain gradient has been studied just in women with PD or pain was assessed as a binary variable (presence or absence). Accordingly, we decided to carry out a study in young women to determine possible factors associated with intense pain.

The V109G polymorphism in the p27 gene is associated with endometriosis

Objective

To investigate the prevalence of the p27 gene polymorphism in women with endometriosis.

Study design

Transversal case–control study. Genomic DNA was extracted from cells collected from buccal swabs. The p27 V109G polymorphism was investigated using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method in a hospital-based Brazilian population.

Results

We analysed the 104 patients and 109 control subjects. The distribution of genotype and allele frequencies of p27 V109G polymorphism was significantly different between the endometriosis cases and healthy women (p = 0.016 and 0.002). Women who had at least one mutated allele presented twofold chances for endometriosis development (OR = 1.9; 95% CI, 1.120–3.343).

Conclusion

The polymorphic variant at codon 109 of the p27 gene seems to be associated with higher risk of endometriosis development.     

Recurrence rate of endometrioma after laparoscopic cystectomy: A comparative randomized trial between post-operative hormonal suppression treatment or dietary therapy vs. placebo

Objective(s)

To assess the recurrence rate of endometrioma after laparoscopic cystectomy plus hormonal suppression treatment or plus dietary therapy compared to post-operative placebo.

Study design

A randomized comparative trial was conducted on 259 consecutive women who underwent laparoscopic unilateral/bilateral cystectomy for endometrioma. Seven days after surgery, the patients were randomly allocated on the basis of a computer-generated randomization sequence, to one of four post-operative management arms as follows: placebo (n = 65) or gonadotrophin-releasing hormone analogue (tryptorelin or leuprorelin, 3.75 mg every 28 days) (n = 65) or continuous low-dose monophasic oral contraceptives (ethynilestradiol, 0.03 mg plus gestoden, 0.75 mg) (n = 64) or dietary therapy (vitamins, minerals salts, lactic ferments, fish oil) (n = 65) for 6 months. At 18 months’ follow-up after surgery, all patients were monitored with a clinical gynecologic examination, and a transvaginal ultrasonography for possible evidence of endometrioma recurrence.

Result(s)

At 18 months’ transvaginal ultrasonographic follow-up after surgery, no significant recurrence rate of endometrioma was detected in women who received a postoperative course of hormonal suppression treatment or dietary therapy when compared with placebo (placebo vs. GnRH-a P = 0.316, placebo vs. estroprogestin P = 0.803, placebo vs. dietary therapy P = 0.544). Second-look laparoscopy was performed on a clinical basis and confirmed the ultrasonographic suspicion of recurrence of endometrioma in all cases: 10 (16.6%) in the post-operative placebo group vs. 6 (10.3%) in the post-operative GnRH-a group vs. 9 (15.0%) in the post-operative continuous estroprogestin group vs. 11 (17.8%) in the post-operative dietary therapy group. Of 36 patients with recurrent ovarian endometriosis, 8 had recurrence on the treated ovary, 20 on the contralateral ovary that appeared to be normal at the time of the first-line surgery, and 8 on both the treated and untreated ovaries. Endometrioma recurrences were associated with moderate-to-severe painful symptoms in 14/36 patients (38.8%), while the remaining 22 (61.1%) patients were asymptomatic.

Conclusion(s)

A 6-month course of hormonal suppression treatment or dietary therapy after laparoscopic cystectomy had no significant effect on the recurrence rate of ovarian endometriosis when compared with surgery plus placebo. So, treatment of endometrioma can be carried out exclusively by laparoscopic cystectomy without post-operative therapy, if a complete excision of ovarian endometriosis has been assured.     

Tratamiento de la endometriosis con 5 mg o 25 mg diarios de mifepristona durante 6 meses. Ensayo clínico aleatorizado,doble ciego

Objectives

To evaluate the safety and efficacy of 5 mg and 25 mg doses of mifepristone for the treatment of endometriosis.

Design

Randomized double-blind study.

Setting

Eusebio Hernández Hospital, Havana, Cuba.

Subjects

Twenty-six women laparoscopically diagnosed with endometriosis were included.

Treatment

Group I received one tablet of 25 mg mifepristone daily and group II received one tablet of 5 mg mifepristone daily for 6 months. Laparoscopy and endometrial biopsy were performed before and after treatment.

Variable to evaluate efficacy

Reduction in the intensity of dysmenorrhea measured by a visual analogue scale.

Results

In both groups reductions in the intensity of dysmenorrhea and dyspareunia were highly significant compared with initial values (P <.001). All the women were amenorrheic after 45 days of treatment.

Conclusions

At doses of 5 mg or 25 mg, mifepristone could be an alternative for the treatment of endometriosis.     

Deep Dyspareunia in Endometriosis: Role of the Bladder and Pelvic Floor

Introduction

The etiology of endometriosis-associated deep dyspareunia may include direct endometriosis-specific factors (eg, stage or invasiveness of disease) and/or indirect contributors such as bladder/pelvic floor dysfunction (eg, related to myofascial mechanisms or nervous system sensitization).

Ovarian carcinoma associated with endometriosis

Objectives

Previous studies have suggested an association between endometriosis and development of ovarian cancer. A study was performed to evaluate the cases of ovarian carcinoma associated with endometriosis.

Study design

The study includes patients with ovarian carcinoma associated with endometriosis diagnosed between 2000 and 2010 at Hacettepe University Hospital, Ankara, Turkey. A total of 1086 patients who underwent surgical staging for ovarian carcinoma were analyzed retrospectively for the presence of histologically documented endometriosis. The clinical and pathological characteristics of 45 ovarian carcinoma patients associated with endometriosis were evaluated including histologic subtype, stage and grade.

Results

Ovarian carcinoma was found to be associated with endometriosis in 4.1% (45/1086) of the cases. Of them, 17 patients (37.8%) had clear cell, 15 (33.3%) had endometrioid, 6 (13.3%) had serous papillary, 4 (8.9%) had mucinous and the remaining 3 patients had an undifferentiated subtype of ovarian carcinoma. Twenty-three (51.1%) patients had stage I, 4 (8.9%) had stage II and 18 (40.0%) had stage III disease. The frequency of coexistence of endometriosis was 20.4% (17/83) for clear cell carcinoma and 9.3% (15/161) for endometrioid cell carcinoma.

Conclusions

Only a small proportion of ovarian cancer cases were found to be associated with endometriosis. Endometriosis was most frequently associated with clear cell and endometrioid types of ovarian carcinoma. Ovarian carcinoma associated with endometriosis seems to represent a distinct disease entity with different histological subtypes, early presentation and a relatively favorable outcome.     

Long-term follow-up after ureteral reimplantation in patients with severe deep infiltrating endometriosis

Objective

To investigate the intraoperative features and long-term postoperative results of patients with ureteral endometriosis who underwent ureteral reimplantation.

Study design

In this retrospective study, we reviewed records of all patients with ureteral endometriosis treated by ureteral reimplantation. Pre-, intra- and post-operative information was collected.

Results

Of patients operated for endometriosis, seven were diagnosed with severe ureteral endometriosis and underwent ureteral reimplantation. Psoas hitch was the preferred technique for the ureteral reimplantation. During a mean postoperative follow up of 42.3 ± 20.0 months, all but one patient reported significant symptomatic improvement. None of the patients needed additional medical or surgical treatment and no recurrence was noted.

Conclusion

Ureteral reimplantation performed by a multidisciplinary surgical team is a suitable technique in selected cases, gives good long-term results and has no need for repeated surgical treatment.