Endometriosis in Adolescents

Background and Objectives:

Women with endometriosis often report onset of symptoms during adolescence; however, the diagnosis of endometriosis is often delayed. The aim of this study was to describe the experience of adolescents who underwent laparoscopy for pelvic pain and were diagnosed with endometriosis: specifically, the symptoms, time from onset of symptoms to correct diagnosis, number and type of medical professionals seen, diagnosis, treatment, and postoperative outcomes.

Methods:

We reviewed a series of 25 females ≤21 years of age with endometriosis diagnosed during laparoscopy for pelvic pain over an 8-year period. These patients were followed up for 1 year after surgery.

Results:

The mean age at the time of surgery was 17.2 (2.4) years (range, 10–21). The most common complaints were dysmenorrhea (64%), menorrhagia (44%), abnormal/irregular uterine bleeding (60%), ≥1 gastrointestinal symptoms (56%), and ≥1 genitourinary symptoms (52%). The mean time from the onset of symptoms until diagnosis was 22.8 (31.0) months (range, 1–132). The median number of physicians who evaluated their pain was 3 (2.3) (range, 1–12). The adolescents had stage I (68%), stage II (20%), and stage III (12%) disease. Atypical endometriosis lesions were most commonly observed during laparoscopy. At 1 year, 64% reported resolved pain, 16% improved pain, 12% continued pain, and 8% recurrent pain.

Conclusions:

Timely referral to a gynecologist experienced with laparoscopic diagnosis and treatment of endometriosis is critical to expedite care for adolescents with pelvic pain. Once the disease is diagnosed and treated, these patients have favorable outcomes with hormonal and nonhormonal therapy.     

不同卵巢储备功能的EMS患者行IVF-ET方案的选择

目的：了解不同卵巢储备功能的子宫内膜异位症( EMS)患者行不同方案的体外受精-胚胎移植( IVF-ET)治疗的结局差异。方法回顾性分析行IVF-ET治疗的337例EMS患者资料。据卵巢储备功能及治疗方案差异分为 A1组(卵巢储备功能正常,超长方案)、A2组(卵巢储备功能正常,长方案)和B1组(卵巢储备功能低下,超长方案)、B2组(卵巢储备功能低下,短方案),比较各组妊娠结局。结果A1组较A2组、B1组较B2组的获卵数、成熟卵母细胞数、受精数、卵裂数、可移植胚胎数及优质胚胎数均低(P<0．05),但卵裂率、可移植胚胎率及优胚率的差异均无统计学意义;A1组新鲜周期及解冻周期胚胎着床率、生化妊娠率、临床妊娠率及活产率均较A2组低( P<0．05),但B1组与B2组新鲜周期及解冻移植( F-ET)周期胚胎着床率、生化妊娠率、临床妊娠率及活产率的差异均无统计学意义。结论采取长方案取卵后行胚胎冷冻、治疗EMS后行F-ET是卵巢储备功能正常的EMS不孕患者IVF-ET最佳方案。     

Decidualization of intranodal endometriosis in a postmenopausal woman

Here we describe an unusual case of decidualized endometriosis detected in pelvic lymph nodes. The presence of intranodal ectopic decidua in pregnant women has been described. A few cases of decidualization of endometriotic foci in the pelvic or para-aortic lymph nodes have also been associated with pregnancy. However, decidualized intranodal endometriosis occurring in a postmenopausal woman has not been described. A 52-year-old woman presented with a very large adnexal mass. Menopause occurred at the age of 47, and she had been treated with hormone replacement therapy. She received a total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic and para-aortic lymphadenectomy for clear cell carcinoma of the right ovary. Histological examination revealed the presence of ectopic decidua in several pelvic lymph nodes. The deciduas consisted of sheets of loosely cohesive, large, uniform, round cells with abundant eosinophilic cytoplasm. Typical of decidualization of intranodal endometriosis, a few irregularly shaped, inactive endometrial glands lined by single layers of columnar to cuboidal epithelium were present within the decidua. An immunohistochemical study revealed that the decidual cells were positive for CD10, vimentin, estrogen receptor and progesterone receptor, which indicated that progestin-induced decidualization had occurred in the intranodal endometriotic stroma. To the best of our knowledge, this case represents the first report of decidualized intranodal endometriosis occurring in association with hormone replacement therapy in a postmenopausal woman. Misdiagnosis of this condition as a metastatic tumor can be avoided by an awareness of these benign inclusions, supported by immunohistochemical staining results.     

MiR-191 inhibits TNF-α induced apoptosis of ovarian endometriosis and endometrioid carcinoma cells by targeting DAPK1

Emerging evidence showed that miRNA dysregulation is involved in the development of endometriosis and may contribute to pathological process of endometriosis associated ovarian cancer (EAOC). miR-191 is one of the most differentially expressed miRNAs in pairwise comparisons among healthy controls, endometriosis, and EAOC patients. However, its regulative network in endometriosis and EAOC are still not clear. This study explored the role of miR-191 in TNF-α induced cell death in ovarian endometriosis and endometrioid carcinoma cells. Based on tissues samples collected from healthy controls, endometriosis, and EAOC patients, this study verified significantly higher expression of miR-191 in endometriosis and endometrioid cancer. Interestingly, we also observed inverse expression trend between miR-191 and DAPK1, a positive mediator of programmed cell death. By conducting luciferase assay, we confirmed miR-191 can directly target DAPK1 and regulate its expression. Functionally, we also found DAPK1 can promote TNF-α induced cell death. DAPK1 knockdown in endometriosis CRL-7566 cells can weaken its response to TNF-α induced cell death, while its overexpression in endometrioid cancer cells CRL-11731 enhanced the response. These functions of DAPK1 can be directly modulated by miR-191. Therefore, the miR-191-DAPK1 axis may play an important role modulating the response of ovarian endometriosis and endometrioid carcinoma cells to death-inducers and might contribute malignant transformation of endometriosis.     

Tumor Necrosis Factor and Interleukin‐6 Gene Polymorphisms and Endometriosis Risk in Asians: A Systematic Review and Meta‐Analysis

A relationship between endometriosis and tumor necrosis factor (TNF‐α) and interleukin‐6 (IL‐6) gene polymorphisms has been raised for Asians. However, this topic is controversial. This study was a meta‐analysis to explore whether TNF‐α/IL‐6 gene polymorphisms were associated with a risk of endometriosis in Asians. By searching PubMed, HuGENet, and China National Knowledge Infrastructure (CNKI) databases, 17 studies were identified and included (3372 cases and 4008 controls). The odds ratio (OR) with 95% confidence interval (CI) was used to assess the association between TNF‐α/IL‐6 gene polymorphisms and endometriosis risk. An association of TNF‐α gene ‐1031T/C polymorphism with endometriosis was found (TT + TC vs. CC: OR 0.50, 95% CI 0.30–0.82, I² = 37.1%, P = 0.20; TT vs. CC: OR 0.50, 95% CI 0.30–0.82, I² = 43.0%, P = 0.173; TC vs. CC: OR 0.49, 95% CI 0.29–0.83, I² = 10.6%, P = 0.327). In addition, TNF‐α‐238A/G and IL‐6 ‐174C/G gene polymorphisms were also likely to be associated with endometriosis in Asians. For the TNF‐α‐238A/G gene polymorphism, the OR was 1.577 (95% CI: 1.01–2.48). For the IL‐6 ‐174C/G gene polymorphism, the OR was 1.554 (95% CI: 1.04–2.31). No associations were detected between the TNF‐α‐308A/G and IL‐6 ‐634C/G polymorphisms and susceptibility to endometriosis. Our results indicate that the TNF‐α gene ‐1031T/C polymorphism can reduce the risk of endometriosis, but for Asians, TNF‐α‐238A/G and IL‐6 ‐174C/G gene polymorphisms may be a risk factor for endometriosis. No association was found for the TNF‐α‐308A/G and IL‐6 ‐634C/G gene polymorphisms.     

Targeting galectin‐1‐induced angiogenesis mitigates the severity of endometriosis

Endometriosis is characterized by the presence of endometrial tissue outside the uterus that causes severe pelvic pain and infertility in women of reproductive age. Although not completely understood, the pathophysiology of the disease involves chronic dysregulation of inflammatory and vascular signalling. In the quest for novel therapeutic targets, we investigated the involvement of galectin‐1 (Gal‐1), an endogenous glycan‐binding protein endowed with both immunosuppressive and pro‐angiogenic activities, in the pathophysiology of endometriotic lesions. Here we show that Gal‐1 is selectively expressed in stromal and endothelial cells of human endometriotic lesions. Using an experimental endometriosis model induced in wild‐type and Gal‐1‐deficient (Lgals1^?/?) mice, we showed that this lectin orchestrates the formation of vascular networks in endometriotic lesions in vivo, facilitating their ectopic growth independently of vascular endothelial growth factor (VEGF) and the keratinocyte‐derived CXC‐motif (CXC‐KC) chemokine. Targeting Gal‐1 using a specific neutralizing mAb reduced the size and vascularized area of endometriotic lesions within the peritoneal compartment. These results underline the essential role of Gal‐1 during endometriosis and validate this lectin as a possible target for the treatment of disease. Copyright © 2014 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.     

Bowel endometriosis: Colorectal surgeon’s perspective in a multidisciplinary surgical team

Endometriosis is a gynecological condition that presents as endometrial-like tissue outside the uterus and induces a chronic inflammatory reaction. Up to 15% of women in their reproductive period are affected by this condition. Deep endometriosis is defined as endometriosis located more than 5 mm beneath the peritoneal surface. This type of endometriosis is mostly found on the uterosacral ligaments, inside the rectovaginal septum or vagina, in the rectosigmoid area, ovarian fossa, pelvic peritoneum, ureters, and bladder, causing a distortion of the pelvic anatomy. The frequency of bowel endometriosis is unknown, but in cases of bowel infiltration, about 90% are localized on the sigmoid colon or the rectum. Colorectal involvement results in alterations of bowel habits such as constipation, diarrhea, tenesmus, dyschezia, and, rarely, rectal bleeding. Differential diagnosis must be made in case of irritable bowel syndrome, solitary rectal ulcer syndrome, and a rectal tumor. A precise diagnosis about the presence, location, and extent of endometriosis is necessary to plan surgical treatment. Multidisciplinary laparoscopic treatment has become the standard of care. Depending on the size of the lesion and site of involvement, full-thickness disc excision or bowel resection needs to be performed by an experienced colorectal surgeon. Long-term outcomes, following bowel resection for severe endometriosis, regarding pain and recurrence rate are good with a pregnancy rate of 50%.     

戴德英教授治疗不同类型子宫内膜异位症经验

[目的]探析戴德英教授临床治疗不同类型子宫内膜异位症的经验。[方法]通过门诊跟师学习,整理相关病例资料,从子宫内膜异位症的临证特点、戴师创制红藤方的思路及针对不同类型内异症的治疗经验三个方面展开,分析戴德英教授运用红藤方治疗不同类型子宫内膜异位症的经验,并附三则验案以验证。[结果]子宫内膜异位症因其表现之"杂"与复发之"勤"而成为妇科疑难病症。戴德英教授究其病因病机为癥积下焦、瘀久化热、瘀热互结、胞脉阻滞,临证注重审证求因,以经方为本,辨证加减,创制红藤方,并根据不同临床表现,结合不同治法,临床每获良效。本文所附三则验案,分别为子宫内膜肺异位,辨证为瘀热内结、肺气不宣;子宫腺肌病,辨证为腑气不通、湿热内结;经行腹痛,辨证为气滞血瘀、蕴而化热,戴师分别予红藤方加减配合调周治疗,中西医结合及中医内外疗法综合治疗,均获良效。[结论]戴德英教授辩证地看待病和证的关系,临床巧用红藤方结合不同治法治疗不同类型子宫内膜异位症,其经验值得后辈学习借鉴。     

子宫内膜异位症从蓄血证论治

[目的]探讨以《伤寒论》蓄血证理论治疗子宫内膜异位症的可行性。[方法]通过跟师学习,结合《伤寒论》中蓄血证相关理论,从病机、证候、治疗几方面阐述子宫内膜异位症与蓄血证之间的相互关系,并列举验案加以分析佐证。[结果]从临床角度看,蓄血证与子宫内膜异位症有相似之处,离经之血瘀滞,瘀热互结下焦是其病因病机,以少腹硬满胀痛、血下则缓为主要临床表现。破结逐瘀是其治疗大法,以抵当汤为治疗主方。临证施治时,根据月经周期、患者体质,在破结逐瘀泻热基础上,佐以补肾、健脾、温经、解痉,并配合针灸治疗。文中所附子宫内膜异位症病案,皆为瘀热互结下焦,从蓄血证论治,以水蛭、地鳖虫祛瘀消散离经之血,以大黄、猫爪草等泻热解毒,并防止病灶的异常出血,取得较好疗效。[结论]以《伤寒论》蓄血证理论治疗下焦瘀热互结的一类疾病,如子宫内膜异位症等,疗效良好,值得临床推广应用。