Correlation between endometriosis and pelvic pain.

STUDY OBJECTIVE: To evaluate the relationship between prevalence and severity of chronic pelvic pain (CPP) and stage, site, and type of endometriosis. DESIGN: Prospective, observational study (Canadian Task Force classification II-2). SETTING: University Hospital. PATIENTS: Of 90 consecutive women with biopsy-proved endometriosis, laparoscopy was performed in 69 for pelvic pain and in 21 for infertility or clinical and ultrasonographic suspicion of ovarian endometriosis. INTERVENTION: Preoperatively, using a 10-point visual analog scale, the severity of dysmenorrhea, CPP, and deep dyspareunia was assessed. During laparoscopy all visible endometriotic lesions were recorded and treated. MEASUREMENTS and MAIN RESULTS: Ten women (11.1%) had no pain; 72 had dysmenorrhea (mild in 13, moderate in 37, severe in 22); 55 had CPP (mild in 11, moderate in 25, severe in 19); and 39 deep dyspareunia (mild in 5, moderate in 31, severe in 3). The severity of dysmenorrhea significantly correlated with the presence and extent of pelvic adhesions (p = 0.004); the severity of CPP correlated with deep endometriosis on the uterosacral ligaments (p = 0.0001) and extent of pelvic adhesions (p = 0.02); and deep dyspareunia correlated with deep endometriosis on the uterosacral ligaments (p = 0.04). Total pain score significantly correlated with deep endometriosis on the uterosacral ligaments (p = 0.0001), peritoneal adhesions (p = 0.01), and extent of adnexal adhesions (p = 0.01). No significant correlation was found among revised American Fertility Society stage of endometriosis; presence and size of ovarian endometriomas; extent, type, and site of peritoneal lesions; and pain scores. By logistic regression analysis, the presence and intensity of total pain could be predicted simultaneously by the presence of deep endometriosis (p = 0.0001) and presence and extent of adnexal adhesions without cystic endometriosis (p = 0.01), and by the presence of ovarian endometrioma with periovarian adhesions (p = 0.03). Chronic pelvic pain was predicted by both deep endometriosis (p = 0.0001) and ovarian endometriomas with adnexal adhesions (p = 0.03). Deep dyspareunia was predicted simultaneously by deep endometriosis (p = 0.01) and an ovarian endometrioma with periovarian adhesions (p = 0. 008). Conclusion. Deep endometriosis, pelvic adhesions, and ovarian cystic endometriosis were independent predictors of pelvic pain. These data strongly suggest that it is not the size of ovarian cystic endometriosis but the association with adhesions that causes pelvic pain.     

AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score

Study ObjectiveTo develop a new endometriosis classification system for scoring intraoperative surgical complexity and to examine its correlation with patient-reported pain and infertility.DesignMulticenter study of patients treated at 3 recognized endometriosis centers.SettingThree specialized endometriosis surgical centers in São Paulo, Brazil and Barcelona, Spain.PatientsPatients aged 15 to 45 years with histologically proven endometriosis and no history of pelvic malignancy underwent laparoscopic treatment of endometriosis.InterventionsDemographic data and clinical history, including dysmenorrhea, noncyclic pelvic pain, dyspareunia, dysuria and dyschezia, were prospectively recorded. All patients were staged surgically according to the new 2021 American Association of Gynecologic Laparoscopists (AAGL) and revised American Society of Reproductive Medicine (ASRM) classification systems. The staging for each system was compared against a 4-level surgical complexity scale defined by the most complex procedure performed.Measurements and Main ResultsA total of 1224 patients undergoing surgery met inclusion criteria. The AAGL score discriminated between 4 stages of surgical complexity with high reproducibility (κ = 0.621), whereas the ASRM score discriminated between the complexity stages with poor reproducibility (κ = 0.317). The AAGL staging system correlated with dysmenorrhea, dyspareunia, dyschezia, total pain score, and infertility comparably with the ASRM staging system.ConclusionThe AAGL 2021 Endometriosis Classification allows for identifying objective intraoperative findings that reliably discriminate surgical complexity levels better than the ASRM staging system. The AAGL severity stage correlates comparably with pain and infertility symptoms with the ASRM stage.     

Leptin is not involved in the pathophysiology of endometriosis-related infertility

OBJECTIVE: Changes in peritoneal fluid (PF) composition may affect fertilization as well as early embryonic development. Leptin, an adipocyte hormone, has been shown to act as a link between adipose tissue and the reproductive system. Therefore, we decided to assess peritoneal and serum leptin levels in infertile endometriotic patients. PATIENTS: Seventy-two women were studied, including 30 fertile and 18 infertile women with ovarian endometriotic cysts and, as a reference group, 24 patients with unexplained infertility. RESULTS: No significant difference in the peritoneal and leptin levels was found between the studied groups. Significantly higher PF leptin concentration was observed in patients with stages III and IV of endometriosis as compared to those with minimal stage of the disease. In fertile patients with endometriosis a positive correlation has been found between PF and serum leptin concentrations. CONCLUSIONS: No differences in peritoneal or serum leptin levels between infertile and fertile women with endometriosis suggest that this cytokine is not involved in pathophysiology of endometriosis-related infertility.     

Increased nitric oxide in peritoneal fluid from women with idiopathic infertility and endometriosis.

OBJECTIVE: To verify whether nitric oxide in peritoneal fluid is associated with endometriosis and infertility. STUDY DESIGN: Twenty-five women with idiopathic infertility and 38 with endometriosis were recruited, and 18 cases of uterine myomata and 2 cases of ovarian cyst served as controls. Peritoneal fluid samples were aspirated from the pouch of Douglas during laparoscopy or laparotomy. Metabolites of nitric oxide (nitrite and nitrate) in peritoneal fluid were determined by a method using nitrate reductase and the Griess reaction. RESULTS: Peritoneal concentrations of nitrate/nitrite in both infertile women (42.02 +/- 12.98 mmol/L) and patients with endometriosis (41.75 +/- 16.42 mmol/L) were significantly higher than that in controls (33.96 +/- 13.07, P < .05 for both). No significant difference in peritoneal nitrate/nitrite level was found between infertile women and patients with endometriosis (P > .5). Peritoneal levels of nitrate/nitrite were comparable among patients with endometriosis at different stages (P > .5). Patients with endometriosis had more peritoneal fluid than controls and idiopathic infertile women, while controls and idiopathic infertile women had comparable amounts of peritoneal fluid. CONCLUSION: An increased peritoneal level of nitric oxide is a common alteration in endometriosis, endometriosis-associated infertility and idiopathic infertility and may be associated with the pathogenesis of these diseases.     

Total antioxidant status of peritoneal fluid in infertile women

OBJECTIVE: To determine whether impairment of the antioxidant systems of peritoneal fluid might be a factor responsible for infertility. STUDY DESIGN: Total antioxidant status was measured in peritoneal fluid obtained from 18 infertile women suffering from minimal or mild endometriosis, 23 patients with unexplained infertility, 12 women with tubal infertility and 13 fertile women. RESULTS: Total antioxidant status was significantly lower in peritoneal fluid from women with unexplained infertility (0.49+/-0.21 mmol/l) compared to both fertile patients (0.67+/-0.24 mmol/l, P=0.02) and women with tubal infertility (0.76+/-0.26 mmol/l, P=0.001). Peritoneal fluid total antioxidant status did not differ significantly between patients with endometriosis (0.61+/-0.2 mmol/l), tubal infertility and the fertile group (P>0.05). CONCLUSIONS: Our results suggest that low antioxidant status in peritoneal fluid may play a role in the pathogenesis of infertility.     

子宫内膜异位症并不孕患者腹腔液淋巴细胞及其白细胞介素-2的变化

目的探讨腹腔液中淋巴细胞转化活性及其释放白细胞介素－２（ＩＬ－２）的含量与子宫内膜异位症患者不孕的关系。方法采集１５例子宫内膜异位症不孕患者（异位症组）及１３例健康生育妇女（对照组）的腹腔液,用形态学观察法测定腹腔液中淋巴细胞转化活性,以生物活性检测法测定腹腔液、腹腔液中淋巴细胞培养上清液的ＩＬ－２含量。结果异位症组淋巴细胞转化率较对照组明显增高（Ｐ＜０．００１）;异位症组腹腔液及淋巴细胞培养上清液中ＩＬ－２的活性明显高于对照组（Ｐ＜０．０１,Ｐ＜０．００１）。异位症组淋巴细胞转化率与淋巴细胞培养上清液中ＩＬ－２活性有明显的直线正相关（Ｐ＜０．００１）。结论ＩＬ－２的含量增加可能是异位症不孕的重要因素。     

Antizona and antisperm antibodies in women with endometriosis and/or infertility

OBJECTIVE: To measure the levels of antigamete antibodies in serum and peritoneal fluid of women with endometriosis and/or infertility. DESIGN: Antibody activity against human sperm and porcine oocytes was analyzed in selected subgroups of women. SETTING: Clinic of reproduction. PATIENT(S): Women with endometriosis and/or infertility. INTERVENTION(S): No treatment was implemented before peritoneal fluid and blood sample collection. MAIN OUTCOME MEASURE(S): Quantitative ELISA. RESULT(S): Four groups of women (n = 98) were analyzed for the presence of antizona and antisperm antibodies: infertile with endometriosis (n = 30), idiopathic infertility (n = 28), fertile with endometriosis (n = 20), and healthy fertile controls (n = 20). Antibodies were analyzed simultaneously in serum and peritoneal fluid. No statistically significant differences in antibody levels were detected in serum samples among the analyzed groups. The median values for antizona and antisperm antibodies in peritoneal fluid were significantly higher in women with idiopathic infertility than in the control group. In women with unexplained infertility, a high degree of correlation (Spearman) was found between the presence of antizona antibodies in peritoneal fluid and serum (r = 0.579). A positive predictive value of 80% was calculated for the presence of antizona antibodies (>5 ng/oocyte) in the peritoneal fluid of patients with infertility. CONCLUSION(S): Antizona antibodies locally produced in the peritoneal fluid have diagnostic value for infertility status; however, they cannot be treated as a marker or prognostic factor for minimal endometriosis and/or its treatment.     

Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis

OBJECTIVE: To investigate whether specific types of pelvic pain are correlated with the anatomic locations of deeply infiltrating endometriosis (DIE). DESIGN: Retrospective data analysis. SETTING: University tertiary referral center. PATIENT(S): Two hundred and twenty-five women with pelvic pain symptoms and DIE. INTERVENTION(S): During surgery, we recorded the anatomic locations of DIE implants and associated endometriosis. MAIN OUTCOME MEASURE(S): We studied the incidence of pelvic pain symptoms including severe dysmenorrhea, deep dyspareunia, noncyclic chronic pelvic pain, painful defecation during menstruation, urinary tract symptoms, and gastrointestinal symptoms as related to the location of DIE. RESULT(S): The frequency of severe dysmenorrhea increased with Douglas pouch adhesions and decreased with parity. The frequency of dyspareunia increased with a uterosacral ligament DIE location and decreased when it involved the bladder. The frequency of noncyclic chronic pelvic pain was higher when it involved the bowel and was lower for women who were treated for infertility. The frequency of painful defecation during menstruation was higher when DIE involved the vagina; lower urinary tract symptoms were more frequent when DIE involved the bladder and less frequent in women with a lower body mass index. Gastrointestinal symptoms were associated with bowel or vaginal DIE locations. CONCLUSION(S): The types of pelvic pain are related to the anatomic location of DIE. Knowledge of the characteristics of pelvic pain symptoms is important in the preoperative assessment of patients with suspected DIE.     

Risk factors for tubal infertility among infertile and fertile women

Data regarding previous pelvic inflammation, abdominal surgery, endometriosis, obstetrical anamnesis, usage of IUD, occurrence of abdominal pain, vaginal discharge and metrorrhagia were obtained from 120 women with tubal infertility and compared to similar data from 126 pregnant women. Previous abdominal surgery, especially pelvic surgery was the most frequent risk factor present in 59% of the infertile women followed by pelvic inflammation (42%) and endometriosis (10%). In 23% of the infertile women there was no history of abdominal surgery, inflammation or endometriosis. Abdominal surgery, inflammation, ectopic pregnancy, salpingectomy and ovarian resection were significantly more frequent among the women with tubal infertility than among the pregnant women. Finally, there was no significant difference in the occurrence of appendectomy, IUD usage, induced or spontaneous abortion.     

子宫内膜异位症患者不同部位病灶中神经纤维分布及其与疼痛症状的关系

目的 探讨子宫内膜异位症(内异症)患者不旧部位病灶组织中神经纤维的分布差异及其与疼痛症状的关系.方法 以2007年9月至2008年9月在北京协和医院行腹腔镜手术治疗的120例内异症患者为研究对象,其中Ⅰ期19例,Ⅱ期29例,Ⅲ期44例,Ⅳ期28例,采用视觉模拟评分(VAS)法,对患并的疼痛症状进行评分,采用免疫组化染色方法检测不同部位内异症病灶组织中神经纤维的分布.结果 不同部位内异症病灶组织中神经纤维的数目依次为:宫骶韧带内异症病灶(29.74±17.33)条/mm~2、阴道直肠隔内异症病灶(24.53±13.34)条/mm~2、子宫直肠陷凹内异症病灶(17.09±10.09)条/mm~2、腹膜内异症病灶(6.77±4.21)条/mm~2、卵巢内异症囊肿壁(0.07±0.25)条/mm~2.其中官骶韧带内异症病灶中神经纤维的数目与痛经关系最密切(r=0.56),子官直肠陷凹以及阴道直肠隔内异症病灶中神经纤维的数目与肛门坠痛(r分别为0.58和0.41)、性交痛(r分别为0.82和0.67)有密切的相关性,均明显高于腹膜及卵巢的内异症病灶.而不同期别患者的内异症病灶组织中神经纤维数目比较,差异无统计学意义(P>0.05).结论 不同部位内异症病灶组织中神经纤维的数目有明显差异性,且与痛经、肛门坠痛、性交痛以及慢性盆腔痛等症状的程度具有相关性,而与临床分期无关.     

Peritoneal macrophages and infertility: the association between cell number and pelvic pathology

Increased numbers of peritoneal macrophages have been repeatedly associated with infertility. Because the factors contributing to this intraperitoneal exudate are unknown, this study was carried out to determine which anatomic or endocrinologic abnormalities in infertile women might be associated with an increase in leukocyte numbers. The peritoneal fluid from 103 women was analyzed. Nonparametric data analysis demonstrated significantly greater cell counts in infertile women with endometriosis, compared with other infertile women (P less than 0.01) or fertile control subjects (P less than 0.005). Multiple regression analysis was then used to determine the relationship of individual variables to cell number without the influence of confounding factors. These data demonstrate that the best correlation with elevated macrophage number is in women who have infertility and no mechanical fertility factors (of which mild endometriosis is a subgroup). Thus, an increase in peritoneal macrophage number is not restricted to women with endometriosis but, rather, is seen in a subset of infertile women generally without mechanical or endocrinologic infertility factors.     

Alternative treatment possibilities of complaints due to endometriosis

Endometriosis is one of the main illnesses affecting women during their fertile age. Symptoms caused by endometriosis include dysmenorrhea, chronic pelvic pain, dyspareunia, menstrual disorders and infertility. Apart from surgical and medical treatment, including hormonal therapies, different alternative treatments exist. Ayurveda, homeopathy, dietary considerations as well as herbal therapies can be used as supplementary treatment for complaints caused by endometriosis. This article gives an overview over these alternative treatments, which many women experience as additionally useful.     

应用腹腔镜诊断和治疗子宫内膜异位症及不孕症的疗效

目的观察应用腹腔镜诊断和治疗盆腔子宫内膜异位症(内异症)及不孕症的疗效.方法对 314例经腹腔镜诊断为盆腔内异症的患者,按1985年美国生育学会修订的内异症分期标准(r-AFS)进行分期,其中Ⅰ期58例,Ⅱ期173例,Ⅲ期68例,Ⅳ期15例;并于腹腔镜下进行卵巢异位内膜病灶切除和粘连分解、盆腔腹膜异位内膜病灶内凝固术及清除腹腔液等手术治疗.术后随访36周,对妊娠者随访到妊娠20周.比较不同r-AFS分期患者术后累计妊娠率和流产率.结果 314例患者术后36周内妊娠共254例,分别为Ⅰ期50例(86.2%,50/58),Ⅱ期141例(81.5%,141/173),Ⅲ期52例(76.5%,52/68)和Ⅳ期11例(73.3%,11/15).经统计学检验,各期患者累计妊娠率比较,差异无统计学意义(P>0.05);术后24周内的妊娠率(93.7%,238/254)高于术后25～36周(6.3%,16/254;P<0.01).254例妊娠患者中,流产12例,流产率与分期无关(P>0.05);妊娠12周内流产率(83.3%,10/12)高于妊娠12周后(16.7%,2/12; P<0.05).结论应用腹腔镜可检查、诊断各期内异症及其引起不孕症的盆腔因素;腹腔镜手术治疗可提高内异症患者的妊娠率.在腹腔镜下清除腹腔液及进行腹腔异位内膜病灶内凝固术,可较完全地破坏盆腔腹膜异位内膜病灶,对各期特别是Ⅰ、Ⅱ期内异症患者生育力的恢复,有重要作用.     

Pain Levels of Women Diagnosed with Endometriosis: Is There a Difference in Younger Women?

Study objectiveEarly diagnosis and treatment of endometriosis affecting adolescent women are important in preventing chronic pain. Our aim was to analyze the clinical characteristics and severity of symptoms in adolescent patients with endometriosis compared with older patients.MethodsThis single-center retrospective cohort study in a tertiary referral hospital analyzed women whose first consultation at the certified endometriosis center of Bern University Hospital between January 2017 and December 2020 resulted in the clinical diagnosis of endometriosis. Patients, divided into 2 groups by age, reported visual analog scale (VAS) scores for noncyclic pelvic pain, dysmenorrhea, dyschezia, dysuria, and dyspareunia. The symptom types and severity in the 2 groups were compared. The young patients with endometriosis were analyzed in greater detail, comparing VAS scores and types of endometriosis.ResultsFrom a total of 826 patients, 144 (17.4%) patients 24 years old or younger and 682 (82.6%) patients over 24 years old were compared. The younger patients reported significantly higher pain scores for dysmenorrhea (VAS 7.3 vs 6.6; P = .015), dyspareunia (VAS 4.6 vs 3.4; P = .001), and noncyclic pelvic pain (VAS 4.3 vs 3.7; P = .032) compared with the older patient collective. Similar results were found when excluding patients with hormonal treatment.ConclusionYoung patients with clinically diagnosed endometriosis have significantly higher dysmenorrhea and dyspareunia pain levels than older patients. By acknowledging and understanding this, early diagnosis and adequate treatment can be promoted. Dyspareunia in adolescents in particular merits clinical attention.     

Management of endometriosis: clinical and biological assessment

No symptom is pathognomonic for endometriosis. Main symptoms are pain (chronic pelvic pain, dysmenorrhea, deep dyspareunia, pain on defecation, cyclic pain) and infertility (grade C). There is no relation between rAFS endometriosis classification and symptoms intensity and frequency (grade B). Endometriosic lesions location and symptoms type are related to each other as well as symptoms intensity and lesions deepness or adhesion numbers (grade B). Clinical evidence is the same for infertile endometriosic women (grade C). Screening for depression is required among patients suffering from chronic endometriosic pelvic pain (grade C). Clinical examination includes: 1) retrocervix area inspection as well as upper part of posterior vaginal wall in search for typical bluish lesions (grade B); 2) vaginal examination in search for: a) uterosacral ligaments nodules (grade B); b) pain in uterosacral ligaments extension (grade B); 3) re-examination during menstruation increases its performance (grade B). No biological check-up in endometriosis diagnosis is necessary (grade A). CA 125 increase is related to: endometriomas and deep lesions volume (grade B), surgically treated infertile women prognosis (grade B). Presurgical endometriosis diagnosis is bettered by using diagnosis pattern in selected population (grade B). Rating scales are recommended in diagnosis and therapeutic follow up (grade B). Quality of life scales are useful to evaluate therapeutic efficiency (grade B).     

子宫内膜异位症非手术诊断方法探讨

目的:评价子宫内膜异位症常见临床指标用于非手术诊断的价值。方法:因痛经、不育或盆腔包块住院行腹腔镜手术的育龄患者331例,术前纪录患者年龄、病程、初潮年龄、月经周期、月经期天数、结婚年龄或第一次性交年龄、孕产次、剖宫产史、继发性痛经、慢性盆腔疼痛、性交痛以及不育,阳性体征(宫骶韧带触痛结节、子宫直肠窝触痛结节或附件包块,具有三者之一者即为阳性),超声波检查(包块内部为无回声区并有散在或密集的光点为阳性),血清CA125值。计算各项临床指标单独及联合应用包括平行试验?系列试验诊断内异症的敏感性?特异性?阳性预测率及阴性预测率,并用Logistic回归方法计算诊断卵巢型及腹膜型内异症的公式。结果:单独应用各项临床指标诊断内异症的敏感性较低。超声波?血清CA125以及性交痛对内异症的预测率达90%以上,其他临床指标预测内异症的准确性较差。临床各项指标联合平行试验可明显提高诊断的敏感性(89%),各项指标联合系列试验则可明显提高诊断的特异性。任何3项临床指标联合,诊断内异症的预测率基本达到100%。卵巢型内异症的诊断公式为:1/[1+e-(-2.270+1.304*盆腔痛性结节+1.158*继发痛经+2.168*B超囊内光点+2.580*CA125异常)],腹膜型内异症的诊断公式为:1/[1+e-(-1.631+1.788*盆腔痛性结节+0.789*继发痛经+2.384*CA125异常)]。以结果>0.5为异常,此公式诊断卵巢型及腹膜型内异症的准确性分别为85.9%和84.5%。结论:疼痛症状、不育、盆腔体征、超声波以及血清CA125联合应用是内异症较准确的非手术诊断方法。     

The nature of the intraperitoneal exudate associated with infertility: peritoneal fluid and serum lysozyme activity

An intraperitoneal inflammatory process has been associated with infertility in women without anatomic distortion of the pelvic viscera, particularly with endometriosis. This phenomenon was investigated by measuring peritoneal fluid (PF) and serum levels of a major secretory product of the macrophage, lysozyme, in fertile and infertile women undergoing laparoscopy. Serum lysozyme levels were in the normal range and did not correlate with total PF lysozyme. Regression analysis revealed a negative correlation between adnexal adhesions and PF volume (P less than 0.05), PF leukocyte number (P less than 0.05), and total PF lysozyme (P less than 0.05). Significant correlations were found between total PF lysozyme and PF volume (r = 0.72, P less than 0.0001) and leukocyte number (r = 0.67, P less than 0.0001). These results suggest that a localized intraperitoneal inflammatory reaction is associated with infertility in the absence of anatomic distortion of the pelvic viscera.     

A relationship between increased peritoneal leptin levels and infertility in endometriosis

Endometriosis is a common, complex and chronic disease related to ectopic implantation and growth of endometrial tissue that may manifest by pelvic pain, and accounts for over 20% of all cases of infertility in women. Endometriosis may be associated with increased levels of leptin in peritoneal fluid. However, the association of leptin with infertility has not been definitely documented. Therefore, the aim of the present study was to search for a relationship between concentrations of peritoneal-fluid leptin and patients' clinical status. The study included 56 patients being diagnosed for infertility and/or pelvic pain. Peritoneal fluid was aspirated during routine laparoscopic examination. Concentrations of leptin in peritoneal fluid were evaluated by a specific enzyme-linked immunosorbent assay. The results revealed that the levels of peritoneal-fluid leptin did not correlate with different stage of endometriosis. However, they correlated with body mass index. Leptin levels were significantly higher in infertile patients than in patients with pelvic pain (p = 0.0023 by Mann–Whitney U test or p = 0.0045 by analysis of variance). It may suggest that increased leptin levels in the peritoneal fluid may play a role in pathogenesis of infertility.     

Is endometriosis really associated with pain?

To address the contrasting findings regarding how pain is related to endometriosis, the relationship between pain and stage of endometriosis was dissected differently by the chief complaint to eliminate selection biases. A total of 1,092 women with endometriosis were classified into two groups depending on their chief complaint, i.e., infertility (infertility group; n = 476) or pain (pain group; n = 616). The correlations between disease stage and various types of pain were analyzed differently in each group. The frequencies of chronic pelvic pain and dyspareunia increased with disease stage either in the infertility group, in the pain group or in the aggregate. On the other hand, no significant relation between the severity of dysmenorrhea and disease stage was observed in the aggregate. Interestingly, a parallel increase in the severity of dysmenorrhea with disease stage was observed in the infertility group, but not in the pain group. In view of selection biases involved in analyzing endometriosis associated with pain, these results could be seen to support the contention that chronic pelvic pain, dyspareunia and dysmenorrhea are in fact related to the extent of endometriosis.     

COX-2 overexpression in peritoneal lesions is correlated with nonmenstrual chronic pelvic pain

OBJECTIVE: To investigate cyclooxygenase (COX-2) expression within different endometriotic lesions and to assess whether these expression patterns correlate with clinical characteristics. DESIGN: Retrospective cross-sectional study. SETTING: University Hospital. PATIENTS: Seventy patients with histologically confirmed exclusively peritoneal (n=20), ovarian (n=19) or deep-infiltrating (n=31) endometriosis and a detailed medical history. INTERVENTION: Immunohistochemical analysis for COX-2 was performed on 108 endometriotic lesions. MEASUREMENTS AND MAIN RESULTS: COX-2 intensity, percentage of stained glandular endometriotic cells, and correlation of COX-2 expression with clinicopathological parameters. Semiquantitative COX-2 expression did not differ between distinct morphological types of endometriosis and showed no association with the menstrual cycle. Patients with peritoneal-only endometriosis suffering from moderate or severe chronic pelvic pain showed significantly more frequent COX-2 overexpression than asymptomatic patients or patients with minimal symptoms. In patients with exclusively ovarian or deep-infiltrating endometriosis no association between COX-2 expression and clinical parameters, such as chronic pelvic pain, dysmenorrhoea, dyspareunia, sterility, lower urinary tract symptoms or gastrointestinal symptoms was observed. CONCLUSION: Peritoneal endometriotic lesions with increased COX-2 expression have a special relevance for the development of chronic, nonmenstruation-associated, pelvic pain in endometriotic patients. These patients may benefit from therapy with COX-2 inhibitors.