J Minim Invasive Gynecol. 2007 Jan-Feb;14(1):33-8.Outcome after rectum or sigmoid resection: a review for gynecologists.Ret Davalos ML, De Cicco C, D'Hoore A, De Decker B, Koninckx PR.Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium. firstname.lastname@example.orgIt remains unclear when to perform a discoid or segmental ...
Fertil Steril. 2012 Sep;98(3):692-701.e5. doi: 10.1016/j.fertnstert.2012.04.022. Epub 2012 May 30
Developing symptom-based predictive models of endometriosis as a clinical screening tool: results from a multicenter study.
To generate and validate symptom-based models to predict endometriosis among symptomatic women prior to undergoing their first laparoscopy.
Prospective, observational, two-phase study, in which women completed a 25-item questionnaire prior to surgery.
Nineteen hospitals in 13 countries.
Symptomatic women (n = 1,396) scheduled for laparoscopy without a previous surgical diagnosis of endometriosis.
MAIN OUTCOME MEASURE(S):
Sensitivity and specificity of endometriosis diagnosis predicted by symptoms and patient characteristics from optimal models developed using multiple logistic regression analyses in one data set (phase I), and independently validated in a second data set (phase II) by receiver operating characteristic (ROC) curve analysis.
Three hundred sixty (46.7%) women in phase I and 364 (58.2%) in phase II were diagnosed with endometriosis at laparoscopy. Menstrual dyschezia (pain on opening bowels) and a history of benign ovarian cysts most strongly predicted both any and stage III and IV endometriosis in both phases. Prediction of any-stage endometriosis, although improved by ultrasound scan evidence of cyst/nodules, was relatively poor (area under the curve [AUC] = 68.3). Stage III and IV disease was predicted with good accuracy (AUC = 84.9, sensitivity of 82.3% and specificity 75.8% at an optimal cut-off of 0.24).
Our symptom-based models predict any-stage endometriosis relatively poorly and stage III and IV disease with good accuracy. Predictive tools based on such models could help to prioritize women for surgical investigation in clinical practice and thus contribute to reducing time to diagnosis. We invite other researchers to validate the key models in additional populations.
Int J Gynaecol Obstet. 2012 Aug;118(2):120-2. doi: 10.1016/j.ijgo.2012.03.036. Epub 2012 May 30.
Safety of transient abdominal ovariopexy in patients with severe endometriosis.
To evaluate complications of transient ovariopexy performed to reduce adhesions in patients with severe endometriosis.
A bicentric retrospective study involved 193 consecutive patients who underwent laparoscopic surgery for severe endometriosis at 2 French university hospitals from 1997 to 2009. At the end of surgery, unilateral or bilateral transient ovariopexy was performed on 297 ovaries. Immediate (e.g. reproducibility, tolerance, and hospital stay) and long-term (evaluated via vaginal access to the ovaries, ovarian function, and ovarian vascularization) complications were assessed.
The technique, which was easy and reproducible, did not increase hospital stay and was well tolerated. There were 2 (0.7%) immediate complications. There was no difference in ovarian accessibility before and after surgery (177/183 [96.7%] vs 176/183 [96.1%]). Potential vaginal oocyte retrieval for in vitro fertilization was possible for all patients. The antral follicle count and the pulsatility index of suspended ovaries were not different from those of contralateral unsuspended ovaries. Endometrioma excision did not modify these results.
The short- and long-term safety results of transient ovariopexy for adnexal adhesions in patients with severe endometriosis were encouraging.
Fertil Steril. 2012 Jul;98(1):36-40. doi: 10.1016/j.fertnstert.2012.04.051. Epub 2012 May 31. Review.
Inflammation: a link between endometriosis and preterm birth.
Endometriosis is a chronic inflammatory disease affecting women’s health. Pain and infertility are the major symptoms caused by a hormonal/immunological dysfunction, which causes an endometrial impairment. The same pathogenetic mechanisms are also associated with preterm birth: hormones, cytokines, neurohormones, and growth factors interact in modulating extracellular matrix and prostaglandin secretion, thus activating the inflammatory process in placental membranes and myometrium. An overlap of molecules and mechanisms may explain the evidence that preterm birth is a common outcome in pregnant patients with endometriosis.
J Minim Invasive Gynecol. 2012 Jul-Aug;19(4):459-64. doi: 10.1016/j.jmig.2012.03.013. Epub 2012 May 30.
Hysterectomy subsequent to endometrial ablation.
To estimate the incidence of and factors associated with hysterectomy subsequent to endometrial ablation.
Retrospective cohort study (Canadian Task Force classification II-2).
Women who underwent endometrial ablation from January 2003 to June 2010, with a minimum follow-up of 9 months.
Endometrial ablation and hysterectomy.
MEASUREMENTS AND MAIN RESULTS:
Of 1169 women, 157 (13.4%) underwent hysterectomy subsequent to endometrial ablation. Women who underwent subsequent hysterectomy were significantly younger at ablation (mean [SD; 95% CI] 39.0 [6.8; 38.0-40.1] years vs 41.4 [7.0; 41.0-41.9] years; p < .001) and were more likely to have previously delivered via cesarean section (26.3 vs 18.1%; p = .02). The rate of hysterectomy was significantly associated with the type of ablation performed: 33.0% for rollerball vs 16.5% for thermal balloon (p = .003), 11.0% for radiofrequency (p < .001), and 9.8% for cryoablation (p < .001). Time to hysterectomy also differed significantly based on the type of ablation performed (p = .006). Adenomyosis was present in 44.4% of hysterectomy specimens.
With a mean follow-up of 39 months, 13.4% of women underwent hysterectomy subsequent to ablation. Women who were younger at ablation had an increased likelihood of hysterectomy. Rate and time to hysterectomy were associated with the type of ablation performed.
Nat Med. 2012 Jul;18(7):1102-11. doi: 10.1038/nm.2826.
A new isoform of steroid receptor coactivator-1 is crucial for pathogenic progression of endometriosis.
Endometriosis is considered to be an estrogen-dependent inflammatory disease, but its etiology is unclear. Thus far, a mechanistic role for steroid receptor coactivators (SRCs) in the progression of endometriosishas not been elucidated. An SRC-1-null mouse model reveals that the mouse SRC-1 gene has an essential role in endometriosis progression. Notably, a previously unidentified 70-kDa SRC-1 proteolytic isoform is highly elevated both in the endometriotic tissue of mice with surgically induced endometriosis and in endometriotic stromal cells biopsied from patients with endometriosis compared to normal endometrium. Tnf⁻/⁻ and Mmp9⁻/⁻ mice with surgically induced endometriosis showed that activation of tumor necrosis factor a (TNF-α)-induced matrix metallopeptidase 9 (MMP9) activity mediates formation of the 70-kDa SRC-1 C-terminal isoform in endometriotic mouse tissue. In contrast to full-length SRC-1, the endometriotic 70-kDa SRC-1 C-terminal fragment prevents TNF-α-mediated apoptosis in human endometrial epithelial cells and causes the epithelial-mesenchymal transition and the invasion of human endometrial cells that are hallmarks of progressive endometriosis. Collectively, the newly identified TNF-α-MMP9-SRC-1 isoform functional axis promotes pathogenic progression of endometriosis.
Clin Med Insights Case Rep. 2012;5:63-8. doi: 10.4137/CCRep.S9530. Epub 2012 May 21.
Leiomyomatosis peritonealis disseminata associated with endometriosisand multiple uterus-like mass: report of two cases.
Leiomyomatosis peritonealis disseminate (LPD) is a rare benign disease of unknown etiology of women in reproductive age. A few reported cases of association with endometriosis have been described suggesting a possible origin from submesothelial multipotential cells. We present two cases of LPD associated with endometriosis expressing smooth muscle metaplasia, and some of the nodules with aspects of uterus-like mass. Laparoscopy, gross findings, and the pathological and immunohistochemical study of the surgical specimens were described. Our findings suggest an endometriotic origin for the LPD and indicate that the therapeutic approach might contemplate the surgical reduction of the nodules and endometriosis treatment.
PLoS One. 2012;7(5):e37750. doi: 10.1371/journal.pone.0037750. Epub 2012 May 25.
Angiotensin II activates the calcineurin/NFAT signaling pathway and induces cyclooxygenase-2 expression in rat endometrial stromal cells.
Cyclooxygenase (COX)-2, the inducible isoform of cyclooxygenase, plays a role in the process of uterine decidualization and blastocyst attachment. On the other hand, overexpression of COX-2 is involved in the proliferation of the endometrial tissue during endometriosis. Deregulation of the renin-angiotensin-system plays a role in the pathophysiology of endometriosis and pre-eclampsia. Angiotensin II increases intracellular Ca(2+) concentration by targeting phospholypase C-gamma in endometrial stromal cells (ESC). A key element of the cellular response to Ca(2+) signals is the activity of the Ca(2+)- and calmodulin-dependent phosphatase calcineurin. Our first aim was to study whether angiotensin II stimulated Cox-2 gene expression in rat ESC and to analyze whether calcineurin activity was involved. In cells isolated from non-pregnant uteri, COX-2 expression–both mRNA and protein–was induced by co-stimulation with phorbol ester and calcium ionophore (PIo), as well as by angiotensin II. Pretreatment with the calcineurin inhibitor cyclosporin A inhibited this induction. We further analyzed the role of the calcineurin/NFAT signaling pathway in the induction of Cox-2 gene expression in non-pregnant rat ESC. Cyclosporin A abolished NFATc1 dephosphorylation and translocation to the nucleus. Cyclosporin A also inhibited the transcriptional activity driven by the Cox-2 promoter. Exogenous expression of the peptide VIVIT -specific inhibitor of calcineurin/NFAT binding- blocked the activation of Cox-2 promoter and the up-regulation of COX-2 protein in these cells. Finally we analyzed Cox-2 gene expression in ESC of early-pregnant rats. COX-2 expression–both mRNA and protein–was induced by stimulation with PIo as well as by angiotensin II. This induction appears to be calcineurin independent, since it was not abrogated by cyclosporin A. In conclusion, angiotensin II induced Cox-2 gene expression by activating the calcineurin/NFAT signaling pathway in endometrial stromal cells of non-pregnant but not of early-pregnant rats. These results might be related to differential roles that COX-2 plays in the endometrium.
Indian Heart J. 2012 May-Jun;64(3):305-8. doi: 10.1016/S0019-4832(12)60093-5.
Uterine artery embolisation.
PURPOSE OF STUDY:
Fibroids are commonest benign tumour of the uterus. It presents with bleeding per vagina in most of the cases. Surgical treatment consists of myomectomy or hysterectomy with or without salpingo oophrectomy, with its inherent morbidity, prolonged hospital stay and psychosocial problems. Surgery is not the best option especially in unmarried and nullipara.
MATERIALS AND METHODS:
Thirty-five patients were subjected to uterine artery embolisation (UAE). Mean age was 35.51 ± 7.36 years. Two patients were suffering from advanced carcinoma of cervix, 32 had fibroid of uterus, one had endometriosis. Three patients were unmarried, three did not have any issue, three had associated haemodynamically significant cardiac disorders, one had polycystic renal disease, and one had hypernephroma. Four patients had multiple fibroids. The UAE was done through contralateral femoral artery puncture, bilaterally, with the help of Judkin’s right coronary catheter. Ultrasound was repeated after 3 months.
The UAE was successful in all patients. Mean procedural time was 75 minutes. Hospital stay was 1 day only. Bleeding stopped in all 35 patients. One patient had recurrence of bleeding after 2 months and underwent surgery. Fibroids disappeared in eight patients, decreased in size by > 75% in 11 patients, and by 50-75% in six patients. Five patients did not report back with ultrasound. Two patients had normal delivery after UAE.
Uterine artery embolisation is effective therapy to stop uterine bleeding. It is effective in controlling the symptoms in uterine fibroids and also decreases the size of fibroids. Hospital stay is only 1 day.
Clinics (Sao Paulo). 2012;67(5):437-41.
A comparison of CA125, HE4, risk ovarian malignancy algorithm (ROMA), and risk malignancy index (RMI) for the classification of ovarian masses.
Differentiation between benign and malignant ovarian neoplasms is essential for creating a system for patient referrals. Therefore, the contributions of the tumor markers CA125 and human epididymis protein 4 (HE4) as well as the risk ovarian malignancy algorithm (ROMA) and risk malignancy index (RMI) values were considered individually and in combination to evaluate their utility for establishing this type of patient referral system.
Patients who had been diagnosed with ovarian masses through imaging analyses (n = 128) were assessed for their expression of the tumor markers CA125 and HE4. The ROMA and RMI values were also determined. The sensitivity and specificity of each parameter were calculated using receiver operating characteristic curves according to the area under the curve (AUC) for each method.
The sensitivities associated with the ability of CA125, HE4, ROMA, or RMI to distinguish between malignant versus benign ovarian masses were 70.4%, 79.6%, 74.1%, and 63%, respectively. Among carcinomas, the sensitivities of CA125, HE4, ROMA (pre-and post-menopausal), and RMI were 93.5%, 87.1%, 80%, 95.2%, and 87.1%, respectively. The most accurate numerical values were obtained with RMI, although the four parameters were shown to be statistically equivalent.
There were no differences in accuracy between CA125, HE4, ROMA, and RMI for differentiating between types of ovarian masses. RMI had the lowest sensitivity but was the most numerically accurate method. HE4 demonstrated the best overall sensitivity for the evaluation of malignant ovarian tumors and the differential diagnosis of endometriosis. All of the parameters demonstrated increased sensitivity when tumors with low malignancy potential were considered low-risk, which may be used as an acceptable assessment method for referring patients to reference centers.
Am J Reprod Immunol. 2012 Sep;68(3):251-7. doi: 10.1111/j.1600-0897.2012.01152.x. Epub 2012 Jun 5.
The role of tissue factor and protease-activated receptor 2 in endometriosis.
Little is known about the roles of TF and PAR-2 in endometriosis. This article investigated the expression of TF and PAR-2 in ectopic and eutopic endometrium with endometriosis and their relationship with the menstrual cycle.
Ectopic and eutopic endometrium tissues from 42 women with ovarian endometrioma and endometrium tissues from 20 women without endometriosis were obtained. All the samples were assessed for TF and PAR-2 protein location using immunohistochemistry and for relative TF and PAR-2 mRNA expression using real-time florescent quantitative polymerase chain reaction (FQ-PCR).
Total TF and PAR-2 expression were significantly higher in ectopic and eutopic endometrium of women with endometriosis when compared with controls. Moreover, TF expression in ectopic and eutopic endometrium and PAR-2 expression in ectopic endometrium were significantly increased through the whole menstrual cycle. However, in eutopic endometrium with endometriosis, PAR-2 expression only in secretory phase was higher than its cycle-matched normal controls. There is no such difference in the proliferative phase.
The abnormal co-upregulated expression of TF and PAR-2 in eutopic and ectopic endometrium may affect the development and growth of endometriotic lesions and highlighted the pathologic role of TF and PAR-2 in eutopic endometrium in endometriosis.
J Obstet Gynaecol Can. 2012 Jun;34(6):552-7.
Clinical predictors of endometriosis in the infertility population: is there a better way to determine who needs a laparoscopy?
Endometriosis is a known contributor to infertility, but the gold standard for its diagnosis is surgical. Therefore, it is important for clinicians to be able to predict which women with infertility are at high risk for endometriosis and thus should be offered laparoscopy. We sought to identify the clinical predictors of endometriosis in the infertility population.
We conducted a retrospective review of patients at an academic infertility centre. The primary outcome was identification of endometriosis at laparoscopy, and we used logistic regression to test clinical variables for their ability to predict endometriosis.
Primary infertility, dysmenorrhea, and uterosacral/cul-de-sac nodularity were significant independent predictors of finding endometriosis at laparoscopy. Other clinical variables (including hysterosalpingogram findings) were not independent predictors of endometriosis, and physicians with an endometriosis-focused practice were more likely to diagnose endometriosis at laparoscopy.
Key predictors of endometriosis in the infertility population are primary infertility, dysmenorrhea, and uterosacral/cul-de-sac nodularity. These results will be used to develop and validate a formal clinical prediction model for endometriosis in infertile women.
Hum Reprod. 2012 Aug;27(8):2247-53. doi: 10.1093/humrep/des192. Epub 2012 Jun 6.
Rationale of first-line endoscopy-based fertility exploration using transvaginal hydrolaparoscopy and minihysteroscopy.
The transvaginal access for exploration of tubo-ovarian function in women with unexplained infertility has been revived since transvaginal hydrolaparoscopy (THL) was introduced in 1998. One prospective double-blind trial and several reviews have validated the diagnostic value of THL in comparison with laparoscopy for the exploration of women with unexplained infertility. A review of the recent literature confirms the efficacy and safety of the technique for first-line endoscopy-based exploration of fertility. The standard policy of 1-year delay for laparoscopic investigation in unexplained infertility is challenged. In older women and particularly in women experienced in fertility awareness methods, THL and minihysteroscopy can be performed after a waiting period of 6-12 months.
Lesion kinetics in a non-human primate model of endometriosis.
Endometriosis is a common cause of pelvic pain and infertility in women of reproductive age. It is characterized by the presence of endometrial tissue outside the normal location, predominantly in the pelvic peritoneum causing severe abdominal pain. However, the severity of the symptoms of endometriosis does not always correlate with the anatomic severity of the disease. This lack of correlation may be due to morphological lesion variation during disease progression. This study examined lesion kinetics in a non-human primate model of endometriosis to better understand lesion dynamics.
Endometriosis was experimentally induced in nine normal cycling female adult olive baboons (Papio anubis) by i.p. inoculation of autologous menstrual endometrium on Day 2 of menses for two consecutive menstrual cycles. Diagnostic laparoscopies were performed between Day 8-12 post-ovulation at 1, 3, 6, 9 and 12 months, followed by a necropsy at 15 months, after the second inoculation. In two animals, lesions were excised/ablated at 6 months and they were monitored for lesion recurrence and morphological changes by serial laparoscopy. Furthermore, five control animals underwent surgeries conducted at the same time points but without inoculation.
A total of 542 endometriotic lesions were observed. The location, macroscopic (different colours) and microscopic appearance confirmed distinct endometriosis pathology in line with human disease. The majority of the lesions found 1 month after tissue inoculation were red lesions, which frequently changed colour during the disease progression. In contrast, blue lesions remained consistently blue while white lesions were evident at the later stages of the disease process and often regressed. There were significantly lower numbers of powder burn, blister and multicoloured lesions observed per animal in comparison to black and blue lesions (P-value≤0.05). New lesions were continually arising and persisted up to 15 months post-inoculation. Lesions reoccurred as early as 3 months after removal and 69% of lesions excised/ablated had reoccurred 9 months later. Interestingly, endometriotic lesions were also found in the non-inoculated animals, starting at the 6-month time point following multiple surgeries.
Documentation of lesion turnover in baboons indicated that lesions changed their colour from red to white over time. Different lesion types underwent metamorphosis at different rates. A classification of lesions based on morphological appearance may help disease prognosis and examination of the effect of the lesion on disease symptoms, and provide new opportunities for targeted therapies in order to prevent or treat endometriosis. Surgical removal of endometriotic lesions resulted in a high incidence of recurrence. Spontaneous endometriosis developed in control baboons in the absence of inoculation suggesting that repetitive surgical procedures alone can induce the spontaneous evolution of the chronic disease. Although lesion excision/ablation may have short-term benefits (e.g. prior to an IVF cycle in subfertile women), for long-term relief of symptoms perhaps medical therapy is more effective than surgical therapy.
Clin Exp Obstet Gynecol. 2012;39(1):65-8.
Immunohistochemical changes of adenomyosis after heat therapy: comparison of radiofrequency myolysis and endoablation.
To check the pathologic changes of focal adenomyosis after heat therapy using radiofrequency and to evaluate which approach–endometrial ablation or direct heat therapy–is better for adenomyosis. To evaluate whether the timing of the procedure and the menstrual cycle are related to pathologic outcomes after heat therapy.
This study included nine women who underwent total hysterectomy for adenomyosis (diameter, > or = 6 cm). Six fresh uteri were excised in the midline and subjected to radiofrequency heat therapy at the center of the adenomyomas (direct heat therapy) and three uteri were subjected to endometrial ablation. Thereafter, 1 cm(3) myometrial tissue was obtained at 1 cm, 2 cm, and 3 cm away from the endometrium. Tissue sections were stained with hematoxylin and eosin. Immunohistochemical analysis using antibodies against cytokerain-19 (CK-19), actin, and estrogen receptor/progesterone receptor (ER/PR) was performed to evaluate CK-19 (endometrial epithelium marker), actin (myometrial marker) and ER/PR (checking the state of the menstrual cycle), respectively.
After endometrial ablation, cauterized tissues were not noted 2 cm away from the endometrium. All tissues between the endometruim and center of adenomyosis were cauterized after direct heat therapy. During the uterine proliferative phase, unlike the secretory phase, subendometrial layers were cauterized 10 min after direct cauterization.
Direct heat therapy is more effective than endometrial ablation in adenomyosis, and heat is conducted effectively when the patients are in the proliferative phase.
Clin Exp Obstet Gynecol. 2012;39(1):107-11.
Effect of fibrin glue and comparison with suture on experimental induction of endometriosis in a rat endometrial autograft model.
The effects of fibrin glue (FG) and suture were investigated and compared with experimental induction in an endometriosis model.
MATERIAL AND METHODS:
A randomized, controlled, and double-blind study was performed with 25 adult female Wistar Albino rats. Two autologous endometrial grafts were obtained from each of the rats. The endometrial grafts were transplanted by gluing with FG on the right abdominal wall and suturing with only 5/0 prolene on the left in ten rats. Gluing+suturing and after suturing over the covering with FG of the endometrial graft were performed, respectively, on the right and left in another ten rats. Covering with FG glue of the endometrial graft was performed in another five rats. The endometriosis-like lesions and intraperitoneal adhesions were evaluated macroscopically and histopathologically.
The mean volume (31.4 +/- 17.3), adhesion (0.8 +/- 0.7) and inflammatory reaction (1.2 +/- 0.7) score of the implants in the group using only FG were significantly lower than in the group using suture [respectively, (49.2 +/- 20.6), (2.4 +/- 0.8), (2.2 +/- 0.8)] (p < 0.05).
Our results demonstrate the general feasibility of reproducible and reliable endometrial graft fixation with FG onto the inner abdominal surface in rats. Furthermore, several advantageous characteristics could be demonstrated such as less inflammation and fewer adhesions.
Diagn Pathol. 2012 Jun 7;7:62. doi: 10.1186/1746-1596-7-62. Review.
Ileocolic intussusception due to a cecal endometriosis: case report and review of literature.
Cecal endometriosis and ileocolic intussusception due to a cecal endometriosis is extremely rare. We report a case of a woman who presented an ileocecal intussusception due to a cecal endometriosis. The patient gave two months history of chronic periombilical pain requiring regular hospital admission and analgesia. The symptoms were not related to menses. A laparotomy was performed and revealed an ileocolic intussusception. The abdominal exploration did not find any endometriosis lesion. Ileocaecal resection was performed. Microscopic examination showed a cystic component, lined by a regular cylindric epithelium. Foci of endometrial tissue were observed in the cecal subserosa and muscularis mucosal, with irregular endometrial glands lined by cylindric epithelium without atypia immunostained with CK7, and characteristic endometrial stroma immunostained with CD10. Cecal endometriosis and ileocolic intussusception due to a cecal endometriosis is extremely rare. Diagnose of etiology remains challenging due to the absence of clinical and radiological specific characteristics.
Ugeskr Laeger. 2012 Jun 11;174(24):1671-3. Danish.
Limited effect of gonadotrophin-releasing hormone analogues for patients with endometriosis.[Article in Danish]
A Cochrane review concluded that gonadotrophin-releasing hormone analogues (GnRHas) are more effective at relieving endometriosis-associated pain than no treatment/placebo, while there was not found any difference in pain relief between GnRHas and danazol or between GnRHas and intrauterine levonorgestrel. A high frequency of hypoestrogenic side effects was found for GnRHas, since none of the studies included add-back therapy. This review confirmed that GnRHas can be used for endometriosistherapy, but first choice of medical treatment should be oral contraceptives or intrauterine levonorgestrel.
J Radiol Case Rep. 2012 Jan;6(1):25-30. doi: 10.3941/jrcr.v6i1.614. Epub 2012 Jan 1.
Thoracic endometriosis: a case report.
Thoracic endometriosis is a rare form of extrapelvic endometriosis. These patients typically present with catamenial pneumothorax or hemoptysis. Adequate clinical history coupled with HRCT helps in early diagnosis and appropriate management of thoracic endometriosis.
J Radiol Case Rep. 2012 Mar;6(3):9-15. doi: 10.3941/jrcr.v6i3.877. Epub 2012 Mar 1.
Herlyn-Werner-Wunderlich syndrome: a rare presentation with pyocolpos.
Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA), also known as Herlyn-Werner-Wunderlich syndrome, is a rare syndrome with only a few hundred reported cases described since 1922. Only a handful of these cases have been associated with pyocolpos. Mullerian duct anomalies have an incidence of 2-3%. While OHVIRA constitutes 0.16-10% of these Mullerian duct anomalies. Symptoms usually present shortly after menarche when hematocolpos develops during menstruation resulting in dysmenorrhea and a pelvic mass. The pelvic mass is the collection of blood products within the obstructed hemivagina. The first study in the diagnostic work-up is usually ultrasonography, which typically demonstrates a pelvic fluid collection which can simulate other disease processes thus confounding the diagnosis. MRI findings of the pelvis reveal a didelphic uterus. Imaging of the abdomen reveals agenesis of the ipsilateral kidney. MRI is beneficial in characterizing the didelphic uterus and vaginal septum for pre-operative planning. Understanding the imaging findings, in conjunction with the clinical presentation, is critical for early diagnosis in attempting to prevent complications such as endometriosis or adhesions from chronic infections with subsequent infertility.
Hum Reprod. 2012 Aug;27(8):2352-8. doi: 10.1093/humrep/des211. Epub 2012 Jun 12.
The value of MRI in assessing parametrial involvement in endometriosis.
What is the accuracy of magnetic resonance imaging (MRI) in the diagnosis of parametrial endometriosis in comparison with surgicopathological findings?
MRI displayed an accuracy of 96.4% in the preoperative diagnosis of parametrial involvement by deep infiltrating endometriosis (DIE).
WHAT IS KNOWN AND WHAT THIS PAPER ADDS:
MRI is the best technique for preoperative mapping of DIE. This preliminary paper shows that T2-weighted MRI is a valuable tool for the preoperative evaluation of parametrial involvement by endometriosis.
A retrospective study of an MRI database was used to identify examinations performed in women, who had a clinical suspicion of pelvic endometriosis (n=666), between 2005 and 2009 in a university medical centre in France.
PARTICIPANTS AND SETTING:
Exclusion criteria were previous surgery for DIE, incomplete surgical evaluation, repeat MRI examinations and incomplete MR protocol. Only symptomatic patients who underwent surgery with a pathological correlation were included (n=83). An experienced radiologist, blind to the surgical and histological findings, evaluated sagittal, axial and thin-section oblique axial MR images obtained from the 83 patients.
DATA ANALYSIS METHOD:
Descriptive statistics and Fisher exact test were used.
The prevalence of DIE and parametrial endometriosis was 76/83 (91.6%) and 12/83 (14.5%), respectively. The sensitivity, specificity, positive and negative predictive values, accuracy and positive and negative likelihood ratios for the diagnosis of parametrial endometriosis of low signal intensity on T2-weighted MRI, pelvic wall involvement and ureteral dilatation, were 83.3%, 98.6%, 90.9%, 97.2%, 96.4%, 59.2 and 0.17, 58.3%, 98.6%, 87.5%, 93.3%, 92.8%, 41.4 and 0.42 and 16.7%, 100%, 100%, 87.7%, 88%, infinity and 0.83, respectively, with the patient as the unit of analysis. BIAS AND LIMITATIONS: The study design was retrospective, and thus prone to bias. Only one experienced reader performed the analysis, so no data are available on intra- or interobserver variability. GENERALISABILITY: At present, no consensus exists on the optimal MR protocol to be used for the evaluation of DIE, thus limiting the wider implications of this study.
STUDY FUNDING AND COMPETING INTERESTS:
No funding was obtained for this study. The authors have no conflict of interest.
Recent Pat Endocr Metab Immune Drug Discov. 2012 Sep;6(3):218-23.
Perspectives of new therapies for endometriosis.
Endometriosis is an inflammatory disease characterized by the presence of endometrial glandular epithelial and stromal cells growing in the extra-uterine environment. The disease affects: ovarian function, oocyte quality, embryo development and implantation, and uterine function resulting in infertility or spontaneous pregnancy loss. Even though the world’s prevalence is above 10 %, an effective treatment has not yet been found. New pharmacological approaches have been designed and patented that could serve as future therapies for this disease.
Hum Reprod. 2012 Sep;27(9):2712-9. doi: 10.1093/humrep/des195. Epub 2012 Jun 13.
National survey of the current management of endometriomas in women undergoing assisted reproductive treatment.
What is the current management of women with ovarian endometriomas undergoing assisted reproductive treatment (ART) in the UK?
It appears that the majority of gynaecologists in the UK offer surgery (mostly cystectomy) for endometriomas prior to ART, regardless of the presence of symptoms.
WHAT IS KNOWN ALREADY:
The ideal management of endometriomas in women undergoing ART remains controversial and presents a dilemma to reproductive specialists.
STUDY DESIGN, SIZE AND DURATION:
This was a national cross-sectional survey. A total of 388 gynaecologists completed the questionnaire.
PARTICIPANTS, SETTINGS AND METHODS:
All clinicians fully registered with the Royal College of Obstetricians and Gynaecologists were contacted. An 11-item survey was administered electronically using Survey Monkey software. Quantitative data were analysed using descriptive and comparative statistics.
MAIN RESULTS AND THE ROLE OF CHANCE:
The majority of responders were consultants (65%), 25% practiced ART and 65% performed laparoscopic surgery. Overall, 95% of responders would offer surgery for endometriomas in women undergoing ART, either on the basis of the size (>3-5 cm) of the endometrioma (52%), the presence of symptoms (16%), the presence of multiple/bilateral endometriomas (2%), regardless of the size and symptoms (19%) or only to women undergoing IVF (6%). The remaining 5% of responders would not offer surgery before ART. Excision was the most common surgical modality (68%), followed by ablation (25%). Laparoscopic surgeons were almost twice as likely to ‘offer surgery to all patients with endometriomas prior to ART’ compared with clinicians performing laparotomy (22 versus 12%, P < 0.001).
LIMITATIONS, REASONS FOR CAUTION:
Our overall response rate, with answers to the questionnaire, was low (15%). However, the response rate amongst reproductive specialists was estimated at 60%. It is possible that there might have been an element of bias towards over-representation of responders who are more concerned about ‘normalization’ of the pelvic anatomy. Furthermore, our survey relied on self-reporting of practice and it is possible that being presented with a list of ‘ideal’ options may have resulted in respondent bias.
WIDER IMPLICATIONS OF THE FINDINGS:
Despite the available evidence that surgery for endometriomas does not improve the outcome of ART and may damage ovarian reserve, it seems that the majority of gynaecologists in the UK offer ovarian cystectomy to their patients.
Endocrinology. 2012 Aug;153(8):3960-71. doi: 10.1210/en.2012-1294. Epub 2012 Jun 14.
Role of estrogen receptor signaling required for endometriosis-like lesion establishment in a mouse model.
Endometriosis results from ectopic invasion of endometrial tissue within the peritoneal cavity. Aberrant levels of the estrogen receptor (ER), ERα and ERβ, and higher incidence of autoimmune disorders are observed in women with endometriosis. An immunocompetent mouse model of endometriosis was used in which minced uterine tissue from a donor was dispersed into the peritoneal cavity of a recipient. Wild-type (WT), ERα-knockout (αERKO), and βERKO mice were donors or recipients to investigate the roles of ERα, ERβ, and estradiol-mediated signaling on endometriosis-like disease. Mice were treated with vehicle or estradiol, and resulting location, number, and size of endometriosis-like lesions were assessed. In comparison with WT lesions in WT hosts, αERKO lesions in WT hosts were smaller and fewer in number. The effect of ER status and estradiol treatment on nuclear receptor status, proliferation, organization, and inflammation within lesions were examined. αERKO lesions in WT hosts did not form distal to the incision site, respond to estradiol, or proliferate but did have increased inflammation. WT lesions in αERKO hosts did respond to estradiol, proliferate, and show decreased inflammation with treatment, but surprisingly, progesterone receptor expression and localization remained unchanged. Only minor differences were observed between WT lesions in βERKO hosts and βERKO lesions in WT hosts, demonstrating the estradiol-mediated signaling responses are predominately through ERα. In sum, these results suggest ER in both endometriosis-like lesions and their environment influence lesion characteristics, and understanding these interactions may play a critical role in elucidating this enigmatic disease.
Fertil Steril. 2012 Sep;98(3):591-8. Epub 2012 Jun 15.
Endometriosis and infertility: a committee opinion.
Women with endometriosis typically present with pelvic pain, infertility, or an adnexal mass, and may require surgery. Treatment of endometriosis in the setting of infertility raises a number of complex clinical questions that do not have simple answers. This document replaces the 2006 ASRM Practice Committee document of the same name.
J Vet Sci. 2012 Jun;13(2):171-7.
The role of inflammation and matrix metalloproteinases in equine endometriosis.
Equine endometriosis is a multifactorial disease considered to be a major cause of equine infertility. The purpose of this study was to evaluate the reliability of histomorphological grading for biopsy-like samples compared to entire uterine wall samples, to examine the association between the degree of endometriosiswith animal age, and to investigate the role of inflammation in endometriosis and the expression of different matrix metalloproteinases in equine endometrium. Histomorphological lesions in 35 uterine samples were examined while comparing biopsy-like samples and entire-wall samples. Seventeen uterine samples were stained with antibodies against MMP-2, MMP-9, MMP-14, and TIMP-2. The morphologic evaluation results of the biopsy-like tissue and entire-wall samples were significantly correlated. Endometriosis in older mares (>12 years of age) was more severe than in young mares (2 ~ 4 years of age), confirming the positive correlation between animal age and disease severity, while inflammation was poorly related to the degree of endometriosis. MMP-2 and MMP-14 were detected in stromal cells, while MMP-9 and TIMP-2 were both found in stromal and glandular epithelial cells. There were no significant differences in MMPs expression between the two groups (young vs. old mares). Additional studies on the activity of MMPs could further define the role of these enzymes in equine endometriosis.
Obstet Gynecol Surv. 2012 Jun;67(6):374-81. doi: 10.1097/OGX.0b013e31825cb12b.
Serum and peritoneal fluid immunological markers in adolescent girls with chronic pelvic pain.
The aim of this study was to determine serum and peritoneal interleukin (IL)-2, IL-4, and monocyte chemotactic protein-1 levels as diagnostic markers of endometriosis in adolescent girls. The design of the study encompassed 50 adolescent girls, aged 13 to 19 years after menarche, with chronic pelvic pain who qualified for diagnostic laparoscopy. The patients were allocated into 2 groups: group I (endometriosis) consisted of subjects with diagnosed endometriosis (n = 33, 66%) and group II (control) whose laparoscopic examinations revealed no evidence of endometriosis (n = 17, 34%). IL-2, IL-4, and Monocyte chemotactic protein 1 concentrations in serum and peritoneal samples were assessed using commercially available human enzyme-linked immunosorbent assay kits. The results were analyzed statistically with the Statistica 8.0 computer software. The value of P < 0.05 was the level of statistical significance. The results in adolescents with endometriosis had significantly higher concentrations of serum IL-4 (3.90 ± 1.58 pg/mL vs. 3.04 ± 1.72 pg/mL; P = 0.04) and peritoneal fluid IL-4 (5.03 ± 8.92 pg/mL vs. 2.74 ± 1.11 pg/mL; P = 0.03), and lower peritoneal fluid IL-2 (92.44 ± 292.75 pg/mL vs. 174.23 ± 389.77 pg/mL; P = 0.01) compared with the control. In a receiver-operating characteristic analysis, serum IL-4 as well as peritoneal fluid IL-2 and IL-4 provided the best discriminative ability between subjects with endometriosis and controls. Using cutoff points for serum IL-4 (3.00 pg/mL), peritoneal fluid IL-2 (21.00 pg/mL) and IL-4 (2.7 pg/mL), relatively high odd ratios were obtained in the prediction of endometriosis in adolescents (3.2; 6.4; 3.3). The Serum IL-4, peritoneal IL-2 and IL-4 provided a good method of discrimination between subjects with endometriosis and controls.
Fertil Steril. 2012 Sep;98(3):713-9. doi: 10.1016/j.fertnstert.2012.05.027. Epub 2012 Jun 19.
Proteomic identification of neurotrophins in the eutopic endometrium of women with endometriosis.
To evaluate neurotrophin (NT) expression in the endometrium of women with and without endometriosis.
Prospective, cross-sectional, translational study.
Thirty-three reproductive-age women undergoing laparoscopy for infertility, pelvic pain, intramural fibroids, or tubal ligation.
Endometrial biopsies, protein microarrays, reverse transcriptase-polymerase chain reaction, ELISAs, and Western blotting.
MAIN OUTCOME MEASURE(S):
Neurotrophin proteins and mRNAs in eutopic endometrial biopsies.
Among seven neurotrophic proteins detected on the antibody microarrays, reverse transcriptase-polymerase chain reaction analysis confirmed nerve growth factor, NT-4/5, and brain-derived neurotrophic factor mRNAs in endometrial tissue. Quantitative ELISAs revealed that NT-4/5 (806 ± 701 vs. 256 ± 190 pg/100 mg protein) and brain-derived neurotrophic factor (121 ± 97 vs. 14 ± 11 ng/100 mg protein) concentrations were significantly higher in women with endometriosis. Nerve growth factor (100 ± 74 vs. 93 ± 83 pg/100 mg protein) levels did not differ between cases and controls.
Neurotrophins are synthesized in situ within the endometrium. NT-4/5 and brain-derived neurotrophic factor proteins were more concentrated in biopsies from endometriosis cases than controls, whereas nerve growth factor levels were similar. We hypothesize that the local production of NTs induces sensory innervation of endometrium of women with endometriosis. These NTs represent novel targets for the diagnosis and treatment of endometriosis.
Hum Reprod Update. 2012 Nov-Dec;18(6):682-702. doi: 10.1093/humupd/dms026. Epub 2012 Jun 19. Review.
Anti-angiogenic treatment strategies for the therapy of endometriosis.
BACKGROUND Angiogenesis, i.e. the development of new blood vessels from pre-existing ones, represents an integral part in the pathogenesis of endometriosis. During the last decade, an increasing number of studies have therefore focused on the anti-angiogenic treatment of the disease. The present review provides a systematic overview of these studies and critically discusses the future role of anti-angiogenic therapy in the multimodal management of endometriosis. METHODS Literature searches were performed in PubMed, MEDLINE and ISI Web of Knowledge for original articles published before the end of March 2012, written in the English language and focusing on anti-angiogenic approaches for the therapy of endometriosis. The searches included both animal and human studies. RESULTS Numerous compounds of different substance groups have been shown to exert anti-angiogenic effects on endometriotic lesions under experimental in vitro and in vivo conditions. These include growth factor inhibitors, endogenous angiogenesis inhibitors, fumagillin analogues, statins, cyclo-oxygenase-2 inhibitors, phytochemical compounds, immunomodulators, dopamine agonists, peroxisome proliferator-activated receptor agonists, progestins, danazol and gonadotropin-releasing hormone (GnRH) agonists. However, clinical evidence for their efficacy in anti-angiogenic endometriosis therapy is still lacking. CONCLUSIONS Anti-angiogenic compounds hold great promise for the future treatment of endometriosis because they may inhibit the establishment of new endometriotic lesions in early stages of the disease or after surgical treatment. Further experimental studies, controlled clinical trials in particular, are required now to clarify which compounds fulfil these expectations without inducing severe side effects in patients with endometriosis.
Vet J. 2012 Dec;194(3):314-8. doi: 10.1016/j.tvjl.2012.04.031. Epub 2012 Jun 20.
Perturbed sperm-epithelial interaction in bitches with mating-induced endometritis.
In several species there is a transient uterine inflammatory response after mating that is purported to clear excess and dead spermatozoa, bacteria and other contaminants from the uterus. In particular individuals this inflammatory response is substantial, resulting in an acute mating-induced endometritis, causing infertility. In this study, the influx of polymorphonuclear neutrophils (PMNs) into the uterine lumen of bitches was investigated after artificial insemination with fresh semen. In normal bitches, an influx of PMNs was detected, followed by high pregnancy rates and normal litter size, and may be a physiological inflammatory response. In bitches with endometrial hyperplasia, there was a larger influx of PMNs and pregnancy rates and litter size were reduced, although the effect was partly ameliorated by the post-mating administration of antibiotics. It is postulated that in bitches with endometrial hyperplasia, post-mating endometritis develops with the potential to affect reproduction adversely. In vitro studies demonstrated a reduced ability of spermatozoa to attach to the uterine epithelium of bitches with endometrial hyperplasia. Moreover, PMNs in the co-culture system inhibited spermatozoal attachment to normal and hyperplastic uterine epithelium, especially hyperplastic epithelium. It was concluded that decreased spermatozoal attachment to uterine epithelium mediates a reduction in fertility of bitches with endometrial hyperplasia. This is the first study to detail an apparent physiological uterine inflammatory response to spermatozoa and its perturbation in bitches with endometrial disease, and the first to recognise the clinical significance and potential aetiology of mating-induced endometritis.
Ann Ital Chir. 2012 Jun 20. pii: S0003469X12018891. [Epub ahead of print]
Rectus abdominis muscle endometriosis Report of two cases and review of the literature.
Endometriosis involving the rectus abdominis muscle is very rare; until now, only 19 such cases have been reported in the medical literature since it was first described in 1984 by Amato and Levitt; almost all were associated with previous abdominal surgery such as cesarean section or other operations. We report two additional cases of this very rare condition presenting with an abdominal mass which was surgically excised with an accompanying margin of normal tissue. Both patients are well and without recurrence. Endometriosis pain has generally been described as cyclical and this condition usually develops in an old surgical scar. Endometriosis has no pathognomonic imaging findings on CT, MRI or sonography, as its appearance depends on the phase of the menstrual cycle, the proportion of stromal and glandular elements, the amount of bleeding and the degree of surrounding inflammatory and fibrotic response. Surgery is the treatment of choice including 5-10 mm of surrounding healthy tissue as surgical margin, to prevent recurrence. Our experience is in agreement with the data of the literature. We suggest that endometriosis must be included in the differential diagnosis of a symptomatic mass in the abdominal wall in women with and without a surgical history. Key words: Endometriosis, Rectus abdominis muscle, Surgery.
Gynecol Obstet Invest. 2012;74(2):151-6. Epub 2012 Jun 21.
Postoperative depot medroxyprogesterone acetate versus continuous oral contraceptive pills in the treatment of endometriosis-associated pain: a randomized comparative trial.
To evaluate the efficacy and tolerability of postoperative depot medroxyprogesterone acetate (DMPA) versus postoperative continuous oral contraceptive (OC) pills in the treatment of endometriosis-associated pain.
After a conservative surgery, 84 patients with symptomatic endometriosis were randomized to receive either intramuscular DMPA (150 mg) every 12 weeks for 24 weeks or continuous OC pills (ethinyl estradiol 0.03 mg and gestodene 0.075 mg) daily for 24 weeks. At weeks 12 and 24 of the treatment phase, patients rated their satisfaction with treatment and reported pain improvement and adverse effects.
There was no significant difference in the percentages of patients who reported satisfaction between the DMPA group and the OC group at weeks 12 and 24 (92.9 vs. 90.5%, and 92.9 vs. 88.1%, respectively). The rates of withdrawal because of persistent pain or side effects in the two groups were similar. Pain scores improved significantly in both groups, but dysmenorrhea scores on a visual analog scale at week 24 were significantly higher in the OC group than in the DMPA group (p = 0.039).
Both postoperative DMPA and postoperative OC pills for 24 weeks were found to be effective and acceptable options for treating endometriosis-associated pain.
J Clin Endocrinol Metab. 2012 Sep;97(9):3146-54. doi: 10.1210/jc.2012-1558. Epub 2012 Jun 20. Review.
The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis.
Endometriomas are mainly treated surgically. However, there has been concern over the potential damaging effect of this surgery on ovarian reserve.
The aim of this meta-analysis was to investigate the impact of surgery for endometriomas on ovarian reserve as determined by serum anti-müllerian hormone (AMH).
MEDLINE, PubMed, and Embase were searched electronically.
All prospective cohort studies that analyzed changes of serum AMH concentrations after surgical treatment of endometriomas were eligible. Twenty-one studies were identified, of which eight were selected for meta-analysis.
Two reviewers performed the data extraction independently.
Pooled analysis of 237 patients showed a statistically significant decrease in serum AMH concentration after ovarian cystectomy (weighted mean difference -1.13 ng/ml; 95% confidence interval -0.37 to -1.88), although heterogeneity was high. Sensitivity analysis for studies with a preoperative serum AMH level of 3.1 ng/ml or greater improved heterogeneity but also still showed a significant postoperative fall in serum AMH (weighted mean difference -1.52 ng/ml, 95% confidence interval -1.04 to -2).
The results of this study suggest a negative impact of excision of endometriomas on ovarian reserve as evidenced by a significant postoperative fall in circulating AMH.
J Gynecol Obstet Biol Reprod (Paris). 2012 Sep;41(5):409-17. doi: 10.1016/j.jgyn.2012.05.006. Epub 2012 Jun 20. Review. French.
Contribution of robot-assisted surgery in the management of female infertility.[Article in French]
Although considerable progresses were made in the field of medically assisted procreation, surgery keeps its place in the therapeutic armamentarium of female infertility. Indeed, its results are very interesting, both in its tubal, myometrial and endometriosis indications. Laparotomy is the first step in the development of any surgical technique. Laparoscopy brings benefits concerning recovery, but also in terms of fertility because of the reduction of postoperative adhesions. Nevertheless, comfort of the surgeon, so the ease of skills, are often altered, especially for complex operations such as those implicated in infertility treatment. Robot-assistance takes here all its interest. It allows indeed a quality in the realization of precise and complex skills, and results at least as interesting as standard laparoscopy can be provided. An overview of robot-assistance in surgery of female infertility is here presented. A review of world literature furnished multiple studies evaluating the tubal robotic surgery, and demonstrating its interesting results. Other indications could, according to us, emerge and be evaluated in this area, such as myomectomy and endometriosissurgery.
Clin Imaging. 2012 Jul-Aug;36(4):295-300. doi: 10.1016/j.clinimag.2011.09.010. Epub 2012 Jun 8. Review.
Pictorial review: rectosigmoid endometriosis on MRI with gel opacification after rectosigmoid colon cleansing.
Posterior deeply infiltrating endometriosis (PDIE) is an invalidating disorder that may involve the rectosigmoid colon. MRI with gel opacification after rectosigmoid colon cleansing improves visualization of rectosigmoid endometriosis. Nonetheless, the depth of bowel wall infiltration is still difficult to assess. In this regard, the use of high-frequency echoendoscope may be needed. Recognition of rectosigmoid endometriosis is important to establish a correct diagnosis and provide counseling and appropriate therapy.
Anim Reprod Sci. 2012 Jun;132(3-4):178-86. doi: 10.1016/j.anireprosci.2012.05.012. Epub 2012 May 28.
Cytological diagnosis of endometritis in the mare: investigations of sampling techniques and relation to bacteriological results.
Aim of this study was to compare uterine smears made using the Knudsen catheter, the cytology brush and a uterine culture swab with regard to diagnostic usefulness and the occurrence of neutrophils. Additionally correlation between culture results and the occurrence of neutrophils in uterine smears was investigated. Samples were collected from 340 mares, 81.5% of which were in estrus. Smears made using the cytology brush yielded more endometrial cells per high-power field than those made using the other two instruments (p<0.0001), and a larger proportion had PMNs compared with smears made using the uterine swab (p<0.0001). For smears made with the cytology brush, cultures of β-hemolytic streptococci were more often (p=0.002) accompanied by PMNs than cultures of bacteria other than β-hemolytic streptococci, and there was a positive correlation (r(s)=0.2 p=0.01) between the number of PMNs in smears and the number of colonies of β-hemolytic streptococci. The cytology brush was superior to the other methods because it generated a larger proportion of diagnostic useful smears and the occurrence of PMNs in smears was significantly correlated with the occurrence of cultures of β-hemolytic streptococci.
Am J Pathol. 2012 Aug;181(2):570-82. doi: 10.1016/j.ajpath.2012.05.010. Epub 2012 Jun 19.
Thrombospondin-1 mimetic peptide ABT-898 affects neovascularization and survival of human endometriotic lesions in a mouse model.
Endometriosis is a common cause of pelvic pain and infertility in women, and a common indication for hysterectomy, yet the disease remains poorly diagnosed and ineffectively treated. Because endometriotic lesions require new blood supply for survival, inhibiting angiogenesis could provide a novel therapeutic strategy. ABT-898 mimics the antiangiogenic properties of thrombospondin-1, so we hypothesized that ABT-898 will prevent neovascularization of human endometriotic lesions and that ABT-898 treatment will not affect reproductive outcomes in a mouse model. Endometriosis was induced in BALB/c-Rag2(-/-)Il2rg(-/-) mice by surgical implantation of human endometrial fragments in the peritoneal cavity. Mice received daily injections of ABT-898 for 21 days. Flow cytometry was performed to measure circulating endothelial progenitor cells in peripheral blood. Cytokines were measured in plasma samples. Half of the ABT-898-treated and control mice were euthanized to assess neovascularization of endometriotic lesions, using CD31(+) immunofluorescence. The remaining mice were mated and euthanized at gestation day 12. Endometriotic lesions increased circulating endothelial progenitor cells 13 days after engraftment, relative to baseline. Endometriotic lesions from ABT-898-treated mice exhibited reduced neovascularization, compared with controls, and lesions had fewer CD31(+) microvessels. Chronic treatment with ABT-898 did not lead to any fetal anomalies or affect litter size at gestation day 12, compared with controls. Our results suggest that ABT-898 inhibits neovascularization of human endometriotic lesions without affecting mouse fecundity.
Fertil Steril. 2012 Sep;98(3):702-712.e6. doi: 10.1016/j.fertnstert.2012.05.035. Epub 2012 Jun 22. Review.
Is early age at menarche a risk factor for endometriosis? A systematic review and meta-analysis of case-control studies.
To review published studies evaluating early menarche and the risk of endometriosis.
Systematic review and meta-analysis of case-control studies.
Eighteen case-control studies of age at menarche and risk of endometriosis including 3,805 women with endometriosis and 9,526 controls.
MAIN OUTCOME MEASURE(S):
Medline and Embase databases were searched from 1980 to 2011 to locate relevant studies. Results of primary studies were expressed as effect sizes of the difference in mean age at menarche of women with and without endometriosis. Effect sizes were used in random effects meta-analysis.
Eighteen of 45 articles retrieved met the inclusion criteria. The pooled effect size in meta-analysis was 0.10 (95% confidence interval -0.01-0.21), and not significantly different from zero (no effect). Results were influenced by substantial heterogeneity between studies (I(2) = 72.5%), which was eliminated by restricting meta-analysis to studies with more rigorous control of confounders; this increased the pooled effect size to 0.15 (95% confidence interval 0.08-0.22), which was significantly different from zero. This represents a probability of 55% that a woman with endometriosis had earlier menarche than one without endometriosis if both were randomly chosen from a population.
There is a small increased risk of endometriosis with early menarche. The potential for disease misclassification in primary studies suggests that this risk could be higher.
Neurocirugia (Astur). 2012 Jul;23(4):170-4. doi: 10.1016/j.neucir.2012.04.009. Epub 2012 Jun 22. Spanish.
Sciatica secondary to extrapelvic endometriosis affecting the piriformis muscle. Case report.[Article in Spanish]
We present a case report of symptomatic compression of the right sciatic nerve notch, secondary to piriformis muscle endometriosis, as well as a literature review.
MATERIAL AND METHODS:
We report the case of a 29-year-old woman with 2-year evolution of right chronic sciatica. During the first year, symptoms were episodic and associated with menstruation. During the second year, sciatica was constant and associated with gait disorder due to sciatic musculature weakness. Mononeuropathy was proved by a neurophysiological study, with MRI and PET studies revealing a mass in the sciatic notch and regional pathological increase in metabolic activity. Surgical treatment was performed in order to release the nerve and obtain a histological sample.
The patient was treated by a transgluteal approach, with external neurolysis of the sciatic nerve and resection of an old-blood cyst at the level of the piriformis muscle. This was subsequently reported as endometriosis by histological examination. The sciatica was resolved after surgery.
Extrapelvic sciatic nerve compression by adjacent endometriosis is very infrequent. Muscle denervation and lack of a histological diagnosis led to surgical exploration of the compression area in order to release the nerve, resect the cause of compression and obtain a definitive diagnosis. The procedure improved all symptoms.
Transl Res. 2013 Mar;161(3):189-95. doi: 10.1016/j.trsl.2012.05.001. Epub 2012 May 31.
Antioxidant supplementation reduces endometriosis-related pelvic pain in humans.
We previously suggested that women with endometriosis have increased oxidative stress in the peritoneal cavity. To assess whether antioxidant supplementation would ameliorate endometriosis-associated symptoms, we performed a randomized, placebo-controlled trial of antioxidant vitamins (vitamins E and C) in women with pelvic pain and endometriosis. Fifty-nine women, ages 19 to 41 years, with pelvic pain and history of endometriosis or infertility were recruited for this study. Patients were randomly assigned to 2 groups: vitamin E (1200 IU) and vitamin C (1000 mg) combination or placebo daily for 8 weeks before surgery. Pain scales were administered at baseline and biweekly. Inflammatory markers were measured in the peritoneal fluid obtained from both groups of patients at the end of therapy. Our results indicated that after treatment with antioxidants, chronic pain (“everyday pain”) improved in 43% of patients in the antioxidant treatment group (P = 0.0055) compared with the placebo group. In the same group, dysmenorrhea (“pain associated with menstruation”) and dyspareunia (“pain with sex”) decreased in 37% and 24% patients, respectively. In the placebo group, dysmenorrhea-associated pain decreased in 4 patients and no change was seen in chronic pain or dyspareunia. There was a significant decrease in peritoneal fluid inflammatory markers, regulated upon activation, normal T-cell expressed and secreted (P ≤ 0.002), interleukin-6 (P ≤ 0.056), and monocyte chemotactic protein-1 (P ≤ 0.016) after antioxidant therapy compared with patients not taking antioxidants. The results of this clinical trial show that administration of antioxidants reduces chronic pelvic pain in women with endometriosis and inflammatory markers in the peritoneal fluid.
Minerva Ginecol. 2012 Aug;64(4):331-5.
Simplified approach to the treatment of endometriosis–ECO system.
The aim of the present study was to develop a system to facilitate the approach for patients with endometriosis, mainly for non-specialized gynecologists.
This was a multicenter study (Canadian Task Force classification II-3). The study aimed to correlate three known parameters for endometriosis, qualifying and quantifying their importance in terms of disease severity and treatment complexity. Patients were divided into three groups.
Each parameter was scored from 0 to 2 in order to determine medical or surgical management for endometriosis based on the clinical and imaging results, where the total score of 0 to 2 was for medical treatment, score 3 was possible medical treatment or surgical and score of 4 to 6 was for surgical intervention. A total score from the three parameters was obtained. Anatomical extent of infiltration and complaints and objective of the patient was helpful in deciding on management of patients with endometriosis.
The ECO system can be a qualified and helpful tool in the approach to patients with suspected endometriosis, mainly for non-specialized gynecologists.
Reprod Sci. 2012 Dec;19(12):1292-301. doi: 10.1177/1933719112450332. Epub 2012 Jun 22.
EMMPRIN is secreted by human uterine epithelial cells in microvesicles and stimulates metalloproteinase production by human uterine fibroblast cells.
- [Reprod Sci. 2015]
Endometrial remodeling is a physiological process involved in the gynecological disease, endometriosis. Tissue remodeling is directed by uterine fibroblast production of matrix metalloproteinases (MMPs). Several MMPs are regulated directly by the protein extracellular matrix metalloproteinase inducer (EMMPRIN) and also by proinflammatory cytokines such as interleukin (IL)1-α/β. We hypothesized that human uterine epithelial cells (HESs) secrete intact EMMPRIN to stimulate MMPs. Microvesicles from HES cell-conditioned medium (CM) expressed intact EMMPRIN protein. Treatment of HES cells with estradiol or phorbyl 12-myristate-13-acetate increased the release of EMMPRIN-containing microvesicles. The HES CM stimulated MMP-1, -2, and -3 messenger RNA levels in human uterine fibroblasts (HUFs) and EMMPRIN immunodepletion from HES-cell concentrated CM reduced MMP stimulation (P < .05). Treatment of HUF cells with low concentrations of IL-1β/α stimulated MMP production (P < .05). These results indicate that HES cells regulate MMP production by HUF cells by secretion of EMMPRIN, in response to ovarian hormones, proinflammatory cytokines as well as activation of protein kinase C.
Curr Opin Obstet Gynecol. 2012 Aug;24(4):245-52. doi: 10.1097/GCO.0b013e3283556285. Review.
Clinical outcome after laparoscopic radical excision of endometriosis and laparoscopic segmental bowel resection.
PURPOSE OF REVIEW:
To present the clinical outcome after laparoscopic radical excision of deeply infiltrative endometriosis (DIE) with colorectal extension and laparoscopic segmental bowel resection.
In three different studies including mostly patients with recurrent DIE with colorectal extension, we showed that radical reconstructive CO2 laser laparoscopic resection of DIE with colorectal extension in a multidisciplinary setting resulted in a low complication rate, a low cumulative reintervention and recurrence rate and a high cumulative pregnancy rate, also when bowel resection reanastomosis was performed. In a systematic review to assess the clinical outcome of surgical treatment of DIE with colorectal involvement, data were reported in such a way that comparison of different surgical techniques was not possible. A checklist is proposed to achieve standardized reporting of presenting symptoms, preoperative tests, inclusion criteria, preoperative and postoperative care, complications, follow-up, patient-centered assessment of pain and quality of life, fertility and recurrence corrected for postoperative use of hormonal suppression or infertility treatment.
CO2 laser laparoscopic radical excision of DIE with colorectal extension and laparoscopic segmental bowel resection in centers of expertise is associated with good clinical outcome. To make real progress, international agreement is needed on terms and definitions used in surgical endometriosisresearch.
Curr Opin Obstet Gynecol. 2012 Aug;24(4):241-4. doi: 10.1097/GCO.0b013e328355626f. Review.
Does minimally invasive surgery for endometriosis improve pelvic symptoms and quality of life?
PURPOSE OF REVIEW:
Endometriosis is a common gynaecological disorder estimated to affect over 70 million women worldwide. In this review we aim to give an overview of postoperative symptoms and look at factors influencing therapeutic choices and surgical techniques.
A wide range of physical and psychological factors contribute to the symptoms of disease. Patients suffer from impaired quality of life, depression, anxiety and chronic and acute pain. Validated questionnaires have been used to assess patient response. Surgical excision of endometriosisimproves dyspareunia and the quality of sex life of patients. It is superior in outcomes to medical therapy in achieving increased pregnancy rates. Catastrophizing and biopsychosocial variables are implicated in the severity of pain experienced in patients with endometriosis. Patients with endometriosis score lower on quality of life assessments and the addition of psychosomatic therapy to medical treatments has shown to improve the emotional status of patients with improved treatment outcomes.
Despite its prevalence, there is no optimal treatment for endometriosis; recurrence of disease is a common problem. Laparoscopic surgery compared with medical therapies shows improved patient satisfaction outcomes in general health, quality of life and emotional wellbeing. Management of this varied aetiology improves in the context of a multidisciplinary team.