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J Clin Endocrinol Metab. 2013 May;98(5):1838-44. doi: 10.1210/jc.2013-1328. Epub 2013 Apr 12.

Clinical review: The use of aromatase inhibitors for ovulation induction and superovulation.

Pavone ME1Bulun SE.




Anovulation is likely responsible for 20% of female infertility. Although clomiphene citrate remains the first-line therapy for ovulation induction in anovulatory patients who are not estrogen-deficient and to treat unexplained infertility, there remains a discrepancy between ovulation and conception rates with its use, attributed to its antiestrogenic effects on cervical mucus and the endometrium. Alternative agents, including aromatase inhibitors, have been used that have not been associated with these side effects.


A literature search was conducted to specifically explore the use of aromatase inhibitors for ovulation induction and superovulation.


Recent studies have found that aromatase inhibitors may be safe and useful agents for ovulation induction in patients with polycystic ovarian syndrome as well a treatment option for superovulation in patients with either unexplained infertility or endometriosis.


Aromatase inhibitors may be an effective alternative treatment to clomiphene citrate for both ovulation induction and superovulation.



Fertil Steril. 2013 Aug;100(2):464-9.

Ovarian damage after laparoscopic endometrioma excision might be related to the size of cyst.

Tang Y1Chen SLChen XHe YXYe DSGuo WZheng HYYang XH.




To investigate the relationship between the size of an excised endometrioma and the magnitude of damage to the ovary after the surgery.


A retrospective, controlled study.


A university hospital.


Eighty-five women with a history of laparoscopic excision of unilateral endometrioma who underwent in vitro fertilization (IVF).


IVF-embryo transfer procedures.


Antral follicle counts (AFC), number of dominant follicles (follicles ≥ 15 mm), and number of oocytes retrieved.


In the group with cyst diameters of ≥ 4 cm and group with cyst diameters of <4 cm, the AFC, number of dominant follicles, and number of oocytes retrieved were decreased in the operated ovaries when compared with those in intact ovaries; in the former group, a statistically significant reduction was observed. The differences of AFC, number of dominant follicles, and number of oocytes retrieved from both ovaries were further compared among the two groups: the decrease in the group with cyst diameters of ≥ 4 cm was higher than in the group with cyst diameters of <4 cm. After adjusting for age and AFC in intact ovaries, similar results were obtained, although AFC only showed a tendency. In addition, the receiver operating characteristic curve analysis revealed a statistically significant, positive correlation between the size of excised cysts and the incidence of fewer than four oocytes retrieved from an operated ovary.


The magnitude of the ovarian damage after laparoscopic endometrioma excision might be related to the size of cyst; the damage to ovaries is more severe when an endometrioma ≥ 4 cm is excised.



Mol Med Rep. 2013 Jun;7(6):1826-30

Infrequent mutations of the PPP2R1A and PPP2R1B genes in patients with ovarian cancer.

Wang F1Zou YLiu FYYu XHHuang HZhang NQi YYLiu RFLiu XYChen JHuang OPHe M.



Protein phosphatase 2, regulatory subunit A, α (PPP2R1A) and β (PPP2R1B) are paralogous subunits of the heterotrimeric protein phosphatase 2 (PP2A) holoenzyme that catalyzes the dephosphorylation of target substrate proteins. Subtype‑specific PPP2R1A mutations have been frequently observed in ovarian and endometrial cancer. Mutations in the paralogous genes were frequently observed in human malignancies. Thus, the present study aimed to analyze the mutation frequencies of the paralogous PPP2R1A and PPP2R1B genes in patients with primary and secondary ovarian cancer. A total of 251 patients with primary (n=234) and secondary (n=17) ovarian cancer were analyzed for the presence of PPP2R1A and PPP2R1B mutations by direct sequencing. For PPP2R1A, a heterozygous, somatic mutation (c.771G>T, p.W257C) was identified in 1 out of 37 patients (2.7%) with primary ovarian endometrioid carcinoma. The mutant sample was that of a 46‑year‑old female, who was also diagnosed with ectopic endometriosis in the benign ovary. No PPP2R1A mutations were detected in the remaining 250 patients with ovarian cancer. For PPP2R1B, no mutations were detected in our samples. The results of this study suggested that PPP2R1A mutations are less common in Chinese patients with ovarian cancer when compared with European and American patients. Furthermore, our study also supported previous observations that PPP2R1B mutations were absent in ovarian cancer, suggesting that PPP2R1B mutations are not actively involved in the pathogenesis of ovarian cancer.




Eur J Gynaecol Oncol. 2013;34(1):86-9

Primary peritoneal low-grade serous carcinoma forming a mass in the colon mimicking a colonic primary carcinoma: a case report.

Tran TA1Holloway RW.



Primary carcinomas of Müllerian origin involving the colon is not an uncommon phenomenon, with most cases reportedly associated with endometriosis. On the other hand, a primary peritoneal low-grade serous carcinoma presenting as a dominant mass in the colon and causing clinical symptoms mimicking a primary colonic carcinoma has not been reported in the literature to the best of the authors’ knowledge. A case of a 66-year-old female patient who presented clinically with rectal bleeding and a rectosigmoid mass is described. The final histologic examination revealed a peritoneal low-grade serous carcinoma forming a dominant mass in the rectosigmoid colon. Of particular interest was a microscopic spectrum of serous epithelial proliferation in the peritoneal cavity and lymph nodes with morphologic features reminiscent of non-invasive and invasive implants in ovarian borderline serous tumors, which most likely denoted the precursors of the tumor in the colon.




Rev Gaucha Enferm. 2012 Dec;33(4):22-32

Essential data set’s archetypes for nursing care of endometriosis patients.

Spigolon DN1Moro CM.



This study aimed to develop an Essential Data Set for Nursing Care of Patients with Endometriosis (CDEEPE), represented by archetypes. An exploratory applied research with specialists’ participation that was carried out at Heath Informatics Laboratory of PUCPR, between February and November of 2010. It was divided in two stages: CDEEPE construction and evaluation including Nursing Process phases and Basic Human Needs, and archetypes development based on this data set. CDEEPE was evaluated by doctors and nurses with 95.9% of consensus and containing 51 data items. The archetype “Perception of Organs and Senses” was created to represents this data set. This study allowed identifying important information for nursing practices contributing to computerization and application of nursing process during care. The CDEEPE was the basis for archetype creation, that will make possible structured, organized, efficient, interoperable, and semantics records.



Cell Death Dis. 2013 Apr 18;4:e592

Iron modulates cell survival in a Ras- and MAPK-dependent manner in ovarian cells.

Bauckman KA1Haller EFlores INanjundan M.



Ovarian cancer is a leading cause of cancer death in women in the United States. While the majority of ovarian cancers are serous, some rarer subtypes (i.e. clear cell) are often associated with endometriosis, a benign gynecological disease. Iron is rich in the cyst fluid of endometriosis-associated ovarian cancers and induces persistent oxidative stress. The role of iron, an essential nutrient involved in multiple cellular functions, in normal ovarian cell survival and ovarian cancer remains unclear. Iron, presented as ferric ammonium citrate (FAC), dramatically inhibits cell survival in ovarian cancer cell types associated with Ras mutations, while it is without effect in immortalized normal ovarian surface epithelial (T80) and endometriotic epithelial cells (lacking Ras mutations). Interestingly, FAC induced changes in cytoplasmic vacuolation concurrently with increases in LC3-II levels (an autophagy marker); these changes occurred in an ATG5/ATG7-dependent, beclin-1/hVps34-independent, and Ras-independent manner. Knockdown of autophagy mediators in HEY ovarian cancer cells reversed FAC-induced LC3-II levels, but there was little effect on reversing the cell death response. Intriguingly, transmission electron microscopy of FAC-treated T80 cells demonstrated abundant lysosomes (confirmed using Lysotracker) rich in iron particles, which occurred in a Ras-independent manner. Although the mitogen-activated protein kinase (MAPK) inhibitor, U0126, reversed FAC-induced LC3-II/autophagic punctae and lysosomes in a Ras-independent manner, it was remarkable that U0126 reversed cell death in malignant ovarian cells associated with Ras mutations. Moreover, FAC increased heme oxygenase-1 expression in H-Ras-overexpressing T80 cells, which was associated with increased cell death when overexpressed in T80 cells. Disruption of intracellular iron levels, via chelation of intracellular iron (deferoxamine), was also detrimental to malignant ovarian cell survival; thus, homeostatic intracellular iron levels are essential for cell survival. Collectively, our results implicate iron in modulating cell death in a Ras- and MAPK-dependent manner in ovarian cancer cells.



Nurse Pract. 2013 May 10;38(5):42-7

Advances in endometriosis treatment.

Sheaves C1.



Endometriosis is a common problem characterized by abdominal pain, back pain, pain with intercourse, dysfunctional uterine bleeding, and infertility. The cause of endometriosis is not well understood, but advances in treatment have been made. Primary care clinicians are uniquely situated to improve patient outcomes by making informed treatment decisions.



Minerva Ginecol. 2013 Apr;65(2):99-103.

Fertility preservation options in women with endometriosis.

Bedoschi G1Turan VOktay K.



Endometriosis is a common, chronic condition in reproductive age women. Although some women may be asymptomatic, most women present with dysmenorrhea, dyspareunia, pelvic pain and/or infertility. Despite the fact that a causal relationship between endometriosis and infertility has not been clearly established, the fecundity rate of untreated women with endometriosis is lower than normal couples. However, suppressive medical therapy for endometriosis has not been shown to improve fecundity rates and may only result in a delay in the use of more effective treatments to achieve pregnancy. In the other hand, surgery for severe endometriosis can be useful to treat infertile women, but several studies reported a lower ovarian reserve after excision of ovarian endometriomas, due to incidental excision of normal ovarian tissue together with the endometrioma wall. Therefore, fertility preservation procedures should be considered to reproductive-age women at risk of impaired fertility related to endometriosis progression or endometriosis surgical treatment. The purpose of this document was to review the current literature regarding fertility preservation techniques for patients diagnosed with endometriosis.



Minerva Ginecol. 2013 Apr;65(2):105-11.

Predictive factors and treatment of recurrence of endometriosis.

Paka C1Miller JNezhat C.



Endometriosis remains an enigmatic disease process. The key is early recognition of symptoms and treatment. Treatment may begin with hormonal suppression. If medical suppression fails or if fertility is desired, surgical intervention should be used. During primary surgical intervention, the goal is for optimal treatment to decrease disease burden. However, despite adequate treatment, reoperation is needed in a good proportion of woman. Factors contributing to recurrence are multifactorial and some can be predicted and some pain recurrence occurs despite obvious evidence. Recurrent surgery should also aim to decrease disease burden and conservative versus definitive treatment is based on patient’s childbearing status. In addition, use of medical treatment can temper recurrence rates. There is still tremendous work that must still be completed in the field of pain recurrence and disease recurrence with endometriosis.



Minerva Ginecol. 2013 Apr;65(2):113-23.

Surgical management of endometriosis.

Monforte M1Poncelet C.



Endometriosis is a complex disease of young women in reproductive age. It’s responsible for dysmenorrhea, dyspareunia, chronic pelvic pain and infertility. Medical and surgical treatments have different aims. Hormonal suppression tends to stop natural evolution of the disease and surgery enables macroscopic excisions of endometriotic implants. Outcomes depend on the stage and the preoperative symptoms. This article summarizes a review of surgical management of endometriosis describing surgical indications, techniques, and outcomes in terms of pain and fertility.


Minerva Ginecol. 2013 Apr;65(2):125-42.

Laparoscopic treatment of endometriosis.

Meuleman C1Tomassetti CGaspar Da Vitoria Magro MVan Cleynenbreugel BD’Hoore AD’Hooghe T.



Endometriosis can be considered as a chronic disease which is characterized by the presence of ectopic endometrium outside the endometrial cavity and which is associated with symptoms as pelvic pain and infertility. Medical treatment is often not sufficient in patients with moderate to severe endometriosis and deep infiltrative endometriosis (DIE), therefore requiring surgical intervention. Over the past 15 years, we have built a multidisciplinary surgical team to perform a radical but fertility preserving resection of extensive endometriosiswith involvement of surrounding organ systems, realizing a good clinical outcome with low complication and recurrence rate, a very good improvement of QOL and a high pregnancy rate. However, for future research evaluating surgical treatment of extensive endometriosis, it is important to reach agreement on study design and on reporting clinical outcome data. A multicenter study with clear patient identification and well defined outcome parameters needs to be set up. Moreover, prevention of DIE with colorectal extension is important, ideally by early identification and management of girls and women at risk. Years of pain and disability as well as a lot of money could be saved when patients, at risk of developing extensive forms of endometriosis could be diagnosed during adolescence.



Minerva Ginecol. 2013 Apr;65(2):143-66.

Role of imaging in the management of endometriosis.

Guerriero S1Spiga SAjossa SPeddes CPerniciano MSoggiu BDe Cecco CNLaghi AMelis GBSaba L.



The imaging techniques have a fundamental role in the diagnosis of endometriosis. Ovarian endometriosis(endometrioma) and deep endometriosis can be recognized using transvaginal ultrasound and/or magnetic resonance imaging (MRI). Although transvaginal ultrasound is the first choice of imaging modality when investigating women with pelvic pain, MRI have a role for the wider field of visions. The reproducibility of both techniques has been investigated. The three-dimensional ultrasonography has been proposed. Also studies regarding unusual localizations are reported in the literature. New insights are present about the role of imaging in the detection of the malignant transformations. This review summarizes the current evidence on the diagnostic accuracy of these two techniques in the pre-surgical assessment of endometriosis.


Minerva Ginecol. 2013 Apr;65(2):167-79.

Endometriosis and cancer: what do we know?

Nassif J1Mattar SAbu Musa AEid A.



Endometriosis is the presence of endometriotic tissue outside of the uterus, composed of endometriotic glands and stroma. It affects between 10% to 12% of women in reproductive age. It presents with dysmenorrhea, dyspareunia, chronic pelvic pain, infertility, urinary or digestive symptoms. Diagnosis is based on clinical suspicion, clinical exam, pelvic ultrasound or pelvic magnetic resonance, and confirmed by laparoscopy with pathology studies. Its management is better understood nowadays. However, its association with neoplasia has been questioned for many years. It probably plays a role in the etiology of gynecological cancers, mainly ovarian neoplasia. In our review, we separately compared endometriosis and endometrioma to cancer, in terms of mutual causality, common risk factors, distinction based on histological findings, in addition to molecular and genetic pathways behind this association. This article reviews the English literature for studies on the association between endometriosis and gynecological cancers. Additional reports were collected by systematically reviewing all references from retrieved papers.



Minerva Ginecol. 2013 Apr;65(2):181-98.

From conception to birth – how endometriosis affects the development of each stage of reproductive life.

Carvalho LF1Rossener RAzeem AMalvezzi HSimões Abrão MAgarwal A.



Increasing evidence suggests that female infertility is associated with endometriosis. Indeed, 40% of women with this disease are infertile. However, a causal relationship has not yet been established, and the possible pathophysiology of infertility in this disease also has not been completely elucidated. In this article, we analyze the mechanisms necessary to achieve a successful live birth in patients with this disease as well as the important steps of fertility, pregnancy and birth that can be impaired in these women. Specifically, we will review new advances in research on folliculogenesis, oocyte quality and sperm quality, egg fertilization, embryo quality, transport through fallopian tube and utero-tubal transport sperm, implantation defects, risk of miscarriage, risk during pregnancy and pre-term delivery. The physiopathology of these alterations and the clinical results of the studies are still very controversial. For these reasons, we can conclude that more research is needed to study the biological pathways of the fertility impairment caused by this disease.


Minerva Ginecol. 2013 Apr;65(2):199-213

Medical management of endometriosis: emerging evidence linking inflammation to disease pathophysiology.

Bruner-Tran KL1Herington JLDuleba AJTaylor HSOsteen KG.



Progesterone action normally mediates the balance between anti-inflammatory and proinflammatory processes throughout the female reproductive tract. However, in women with endometriosis, endometrial progesterone resistance, characterized by alterations in progesterone responsive gene and protein expression, is now considered a central element in disease pathophysiology. Recent studies additionally suggest that the peritoneal microenvironment of endometriosis patients exhibits altered physiological characteristics that may further promote inflammation-driven disease development and progression. Within this review, we summarize our current understanding of the pathogenesis of endometriosis with an emphasis on the role that inflammation plays in generating not only the progesterone-resistant eutopic endometrium but also a peritoneal microenvironment that may contribute significantly to disease establishment. Viewing endometriosis from the emerging perspective that a progesterone resistant endometrium and an immunologically compromised peritoneal microenvironment are biologically linked risk factors for disease development provides a novel mechanistic framework to identify new therapeutic targets for appropriate medical management.



Reprod Sci. 2013 Nov;20(11):1332-8.

Effect of nitric oxide and TH1/TH2 cytokine supplementation over ectopic endometrial tissue growth in a murine model of endometriosis.

Mier-Cabrera J1González-Gallardo SHernández-Guerrero C.



Using a murine model, we evaluated the growth of ectopic endometrial tissue in the presence of T helper 1 (Th1) or Th2 cytokines or a nitric oxide donor (S-nitroso-N-acetyl-penicillamine [SNAP]). Female mice were autografted with endometrial tissue in the peritoneum. Different combinations and concentrations of cytokines or SNAP were injected intraperitoneally for 8 weeks. Implants were recovered, measured, and weighed. Cytokines were determined in plasma. Implants (weight and area) were smaller in mice that received interferon γ plus interleukin 2 (IFN-γ + IL-2) compared to mice treated with IL-2, IL-4 + IL-10 or saline solution, and saline solution compared to different concentrations of SNAP. The IL-2, IFN-γ, and IL-4 concentrations in plasma decreased in accordance with the increase in SNAP concentrations compared to saline solution. The promotion of a Th1 milieu in the peritoneum reduced the weight and area of the implant. Different concentrations of SNAP suppressed Th1 and Th2 cytokines and enabled the growth of the implant in this murine model.




Oncol Lett. 2013 Apr;5(4):1253-1257.

Malignant transformation of residual endometriosis following hysterectomy and bilateral salpingo-oophorectomy in a female patient from a family with hereditary non-polyposis colorectal cancer.

Chen Y1Zhai YJiang XZhang Z.



The aim of this study was to report a case of malignant transformation from residual endometriosis following hysterectomy and bilateral salpingo-oophorectomy in a female patient with a positive family history of ovarian and colon cancer resulting from residual endometriosis. A 42-year-old female patient from a family with hereditary non-polyposis colorectal cancer (HNPCC) diagnosed with bilateral ovarian endometriosis underwent a hysterectomy and bilateral salpingo-oophorectomy. Two years later, the patient was diagnosed with malignant ovarian cancer. Histological examination revealed an endometrioid adenocarcinoma with transitions between endometriosis and adenocarcinoma. The patient was diagnosed with ovarian endometrioid carcinoma, at FIGO stage IIC. In future, the family history of female patients with endometriosis should be collected. The association between the malignant transformation of endometriosis and HNPCC should be studied further in a research setting.



J Med Life. 2013 Mar 15;6(1):68-71.

Case study of a rare form of endometriosis.

Cirstoiu M1Bodean OSecara DMunteanu OCirstoiu C.



Endometriosis is a common, benign, chronic, estrogen-dependent disorder. The endometrial tissue implants itself outside the uterus and can be usually found in the pelvis or, in rare cases, it can be found nearly anywhere in the body. There are no pathognomonic symptoms of this disease, therefore, in some cases the tumors are incidentally discovered during surgery. Deep infiltrative endometriosis (DIE) is a rare form of this condition, which mostly affects the uterosacral ligaments, the rectovaginal space, and the upper third of the posterior vaginal wall, the bowel, and the urinary tract. We present the case of a 29-year-old pregnant female who was diagnosed with infiltrative endometriosis during the cesarean section at 38 weeks of gestation. The tumors involving the vesicouterine peritoneum had a tendency of infiltrating the urinary bladder, but the patient had been completely asymptomatic prior to this incidental discovery. As cited by literature, the discovery and management of urinary endometriosis, as well as that of other localizations of DIE, is not based on high-level evidence data, but rather on case-series reported by surgical teams working in different centers worldwide.




J Pediatr Adolesc Gynecol. 2013 Aug;26(4):e93-4

Persistence of endometriosis after correction of an obstructed reproductive tract anomaly.

Silveira SA1Laufer MR.




Endometriosis is commonly found in adolescents with an obstructed reproductive tract and has been reported to always regress after correction. This study highlights 5 patients who had persistent pain and a diagnosis of endometriosis following correction of their anomaly.


The cases include patients with agenesis of the lower vagina or an obstructed hemivagina. All had recurrence of pain 6 months to 5 years after their corrective surgery. Laparoscopy revealed Stage I, II, and IV endometriosis.


This case series reveals that endometriosis does not always resolve following repair of an obstructive anomaly. This may result from prior/ongoing peritoneal seeding or other factors. Given possible disease progression and potential adverse effect on fertility, it important to consider laparoscopy and medical therapy if these patients have persistent pain.




Pain. 2013 Jun;154(6):874-81

Efficacy of melatonin in the treatment of endometriosis: a phase II, randomized, double-blind, placebo-controlled trial.

Schwertner A1Conceição Dos Santos CCCosta GDDeitos Ade Souza Ade Souza ICTorres ILda Cunha Filho JSCaumo W.



Endometriosis-associated chronic pelvic pain (EACPP) presents with an intense inflammatory reaction. Melatonin has emerged as an important analgesic, antioxidant, and antiinflammatory agent. This trial investigates the effects of melatonin compared with a placebo on EACPP, brain-derived neurotrophic factor (BDNF) level, and sleep quality. Forty females, aged 18 to 45 years, were randomized into the placebo (n = 20) or melatonin (10 mg) (n = 20) treatment groups for a period of 8 weeks. There was a significant interaction (time vs group) regarding the main outcomes of the pain scores as indexed by the visual analogue scale on daily pain, dysmenorrhea, dysuria, and dyschezia (analysis of variance, P < 0.01 for all analyses). Post hoc analysis showed that compared with placebo, the treatment reduced daily pain scores by 39.80% (95% confidence interval [CI] 12.88-43.01%) and dysmenorrhea by 38.01% (95% CI 15.96-49.15%). Melatonin improved sleep quality, reduced the risk of using an analgesic by 80%, and reduced BNDF levels independently of its effect on pain. This study provides additional evidence regarding the analgesic effects of melatonin on EACPP and melatonin’s ability to improve sleep quality. Additionally, the study revealed that melatonin modulates the secretion of BDNF and pain through distinct mechanisms.




Lijec Vjesn. 2013 Jan-Feb;135(1-2):33-40.

Piriformis muscle syndrome: etiology, pathogenesis, clinical manifestations, diagnosis, differential diagnosis and therapy.

Grgić V1.



The term ‘piriformis syndrome’ (PS), introduced by Robinson in 1947, implies a group of signs and symptoms caused by piriformis muscle (PM) disorders. Since PM disorders lead to irritation/compression of the anatomic structures passing under its belly, the main clinical PS signs and symptoms are actually the clinical signs and symptoms of irritation/ compression of neural and vascular structures passing through the infrapiriform foramen: sciatic nerve/SN, inferior gluteal nerve, posterior femoral cutaneous nerve, pudendal nerve, inferior gluteal artery and vein and inferior pudendal artery and vein. The clinical picture is usually dominated by signs and symptoms of irritation/compression of SN (SN irritation –> low back and buttock pain, sciatica,paresthesias in distribution of SN; SN compression –> low back and buttock pain,sciatica, paresthesias and neurologic deficit in distribution of SN). Irritation/compression of other structures can result in the following signs and symptoms: inferior gluteal nerve –> atrophy of gluteal muscles; posterior femoral cutaneous nerve –> pain, paresthesias and sensory disturbances in the posterior thigh; pudendal nerve –> pudendal neuralgia, painful sexual intercourse (dyspareunia), sexual dysfunction, urination and defecation problems; inferior gluteal artery –> ischemic buttock pain; inferior pudendal artery –> ischemic pain in the area of external sex organs, perineum and rectum, sexual dysfunction, urination and defecation problems; inferior gluteal vein –> venous stasis in gluteal area; inferior pudendal vein –> venous stasis in external sex organs and rectum. Functional/non-organic and organic PM disorders can cause PS: spasm, shortening, hypertrophy, anatomic variations, edema, fibrosis, adhesions, hematoma, atrophy, cyst, bursitis, abscess, myositis ossificans, endometriosis, tumors (functional disorders: PM spasm and shortening). The most common causes for PS are PM spasm, shortening and hypertrophy and anatomic variations of PM and SN. In 5-6% of patients with low back pain and/or unilateral sciatica, the pain is caused by PM disorders. PS diagnosis can be made on the basis of anamnesis, clinical picture, clinical examination, EMNG, perisciatic anesthetic block of PM and radiological exams (pelvis/PM MRI; MR neurography of LS plexus and SN). PS therapy includes medicamentous therapy, physical therapy, kynesitherapy, acupuncture, therapeutic perisciatic blocks, botulinum toxin injections and surgical treatment (tenotomy of PM, neurolysis of SN).



Steroids. 2013 Sep;78(9):909-19.

Synthesis and antiprogestational properties of novel 17-fluorinated steroids.

Nickisch K1Nair HBKesavaram NDas BGarfield RShi SQBhaskaran SSGrimm SLEdwards DP.



Progesterone receptor (PR) plays a key role in reproductive functions, and compounds that inhibit progesterone action (antiprogestins) have potential use in the treatment of estrogen- and progesterone-dependent diseases, including uterine leiomyomas and breast cancer. In the present study, we chemically synthesized novel 17-fluorinated steroids and evaluated the cytotoxicity profiles of these compounds in T47D breast cancer cells compared to the activity of known antiprogestins, including ZK230 211, RU-486, CDB2914, CDB4124 and ORG33628. We analyzed in vitro receptor-binding assays and PR-transactivation assays to establish the antiprogestational activity of these molecules. The representative antiprogestin EC304 was found to inhibit in vitro tumorigenicity in a dose-dependent fashion in T47D cells by a colony formation assay at 1 and 10nM concentrations. The potent in vivo antiprogestational activity of EC304 was also demonstrated in an antinidation assay for the interruption of early pregnancy in rats. The strong antiprogestational activity and absence of antiglucocorticoid activity in EC compounds may demonstrate their utility in the treatment of leiomyoma, endometriosis and breast cancer.



BMJ Case Rep. 2013 Apr 22;2013.

Cervical tourniquet in case of uncontrollable haemorrhage during caesarean section owing to a placenta accreta.

Huijgen QC1Gijsen AFHink EVan Kesteren PJ.



This case report describes a 38-year-old woman in whom a primary caesarean section for placenta previa was complicated by postpartum haemorrhage due to a placenta accreta. Despite tamponade with a Bakri balloon and placement of a B-Lynch suture, the amount of blood loss could not be effectively reduced. The blood loss was eventually minimised by the placement of a Penrose drain around the cervix as a cervical tourniquet. We think that a cervical tourniquet is an effective method of stopping haemorrhage during caesarean section, as shown in this case report, and we consider this technique to be a valuable addition to several existing methods through which fertility is preserved by preventing emergency hysterectomy.




Klin Khir. 2013 Jan;(1):60-4.

Peculiarities of endovideosurgical diagnosis and treatment of infertility in women with chronic pelvic pain.

Dubchak AIeRaksha IIDubenko ODMandziĭ IM.



Laparoscopy was performed in women for diagnosis and treatment of infertility and chronic pelvic pain (CHPP). While laparoscopy performance in all the women there was revealed the adhesion process in the region of the uterine accessories, in 42.5% of them–in a small pelvis and abdominal organs, more frequently various forms of genital endometriosis were revealed, and it is interesting, that it was revealed for the first time in 33.75% of women intraoperatively. Coexistence of adenomyosis and external genital endometriosis was noted in 51.25% observations, what is trustworthy more, than in women, suffering infertility without CHPP. The concomitant affection rate is trustworthy enhanced, than in women, suffering infertility without CHPP.






Genet Mol Res. 2013 Apr 2;12(2):1035-44.

Vascular endothelial growth factor gene polymorphisms contribute to the risk of endometriosis: an updated systematic review and meta-analysis of 14 case-control studies.

Li YZ1Wang LJLi XLi SLWang JLWu ZHGong LZhang XD.



Endometriosis is a chronic gynecological disease defined as the presence of the endometrium outside the uterine cavity. Endometriosis is a multifactorial and polygenic disease in which angiogenesis may be implicated. Angiogenesis is under the control of numerous inducers, including vascular endothelial growth factor (VEGF). Many studies have reported that VEGF plays a role in the progression of the disease, but individually published studies showed inconclusive results. We investigated the association between VEGF polymorphisms and the susceptibility to endometriosis. The MEDLINE, EMBASE, Web of Science, and CBM databases were searched for all articles published up to June 25, 2012, which addressed VEGF polymorphisms and endometriosis risk. We investigated the potential association between VEGF polymorphisms and the risk of endometriosis. Fourteen studies were included with a total of 3313 endometriosis cases and 3393 healthy controls. Meta-analysis results showed that the rs699947 (A>C) and rs1570360 (G>A) polymorphisms in the VEGF gene were associated with a decreased risk of endometriosis, while rs3025039 (C>T) might increase the risk of endometriosis. However, the rs833061 (T>C) and rs2010963 (G>C) polymorphisms of the VEGF gene did not appear to have an influence on endometriosis susceptibility. Results from the meta-analysis suggest that the rs3025039 (C>T) polymorphism of the VEGF gene increases the risk of endometriosis, but the rs699947 (A>C) and rs1570360 (G>A) polymorphisms might be protective factors for endometriosis.



Clin Exp Reprod Med. 2013 Mar;40(1):29-32

Natural conception rate following laparoscopic surgery in infertile women with endometriosis.

Lee HJ1Lee JEKu SYKim SHKim JGMoon SYChoi YM.




To investigate the influence of laparoscopic surgery on the natural conception rate in infertile women with endometriosis during the first year after the operation.


We retrospectively studied 43 infertile women with surgically proven endometriosis. The natural conception rate was investigated for the 12 months after the laparoscopy.


The overall pregnancy rate was 41.9% (18/43). 66.7% (12/18) and 94.4% (17/18) of the patients conceived within postoperative 3 months and 6 months, respectively. The spontaneous pregnancy rate was not associated with the severity of endometriosis or laparoscopic findings or the type of surgery. The pregnancy rate for stage IV was relatively low (20.0%) compared to stage I, II, and III (35.7%, 44.4%, and 53.3%, respectively), although it did not reach statistical significance.


Conservative surgical treatment with laparoscopy and a prompt attempt at natural conception may be effective for infertile patients with endometriosis.



Arch Gynecol Obstet. 2013 Nov;288(5):1061-6.

Prophylactic pre-operative bilateral ureteric catheters for major gynaecological surgery.

Merritt AJ1Crosbie EJCharova JAchiampong JZommere IWinter-Roach BSlade RJ.




The use of prophylactic pre-operative bilateral ureteric catheters for major gynaecological surgery is controversial. The aim of this study was to investigate the frequency of ureteric catheter-associated morbidity in our Unit, where systematic pre-operative ureteric catheterisation is performed.


We conducted a retrospective casenote review of 337 gynaecology patients undergoing laparotomy at Salford Royal Hospital between January 2007 and September 2010.


The mean age was 56.36 (range 17-89). Procedures included TAH BSO (n = 249, 74 %), BSO (n = 17, 5 %), radical hysterectomy (n = 36, 11 %), and other (n = 35, 10 %), for indications of ovarian (n = 189, 56 %), uterine (n = 88, 26 %) or cervical cancer (n = 18, 5.3 %), massive fibroids (n = 27, 8 %), severe endometriosis (n = 6, 1.78 %), or other (n = 9, 2.67 %). Bilateral ureteric catheters were attempted in most patients and successfully placed in 315/337 (93 %) patients. In 22 patients (7 %), either no ureteric catheters or a single ureteric catheter was placed due to pre-existing ureteric anomaly, technical difficulty, or surgeon choice. Bilateral ureteric catheterisation took an average of 5.4 min (SD 2.0, range 3.2-9.2) for an experienced consultant or 8.4 min (SD 3.9, range 6.4-18.6) for an SpR trainee to complete. There were no intra-operative ureteric complications. Post-operative complications included urinary tract infection (5/337 patients, 1.48 %), acute renal failure (2/337, 0.6 %), and uretero-vaginal fistulae (1/337 patients, 0.3 %).


Prophylactic pre-operative ureteric catheters are quick and easy to insert and associated with low complication rates. Routine use before major gynaecological surgery can expedite intra-operative identification of the ureters and may reduce accidental ureteric injury.




J Invest Surg. 2013 Oct;26(5):283-93.

The use of live fluorescence staining techniques in surgery: a review.

Roberts HW1Donati-Bourne JFWilson VLWilton JC.

Author information


Intraoperative fluorescence may allow improvements to existing surgical procedures or offer scope for new operations. Despite articles describing its use dating back more than a decade, its emergence as a commonly used adjunct is still anticipated. While awareness and availability of special equipment may limit the uptake of these techniques, intraoperative fluorescence could represent a key innovation in the future of surgery. Further awareness of techniques and more clinical trials are needed to promote a wide base of clinical expertise from which further innovations can be made. This literature review begins with a discussion of the physics and chemistry of fluorophores and the properties needed for use in clinical practice. Uses in the majority of surgical specialties will be considered and the current literature addressed. Common uses include delineating hollow visci such as blood vessels or demonstrating pathology such as tumors. Fluorescent stains used have been safe, effective, and often easier to use than the established methods. Finally, novel materials such as antibodies and nanoparticles will be mentioned as new developments on the horizon of intraoperative fluorescent staining.



J Minim Invasive Gynecol. 2013 Jul-Aug;20(4):412.

Laparoscopic sigmoidectomy for endometriosis with transanal specimen extraction.

Messori P1Faller EAlbornoz JLeroy JWattiez A.




To describe a more conservative and less invasive surgical approach to laparoscopic colorectal segmental resection for treatment of endometriosis.


Video of elective sigmoidectomy to treat colorectal endometriosis.


Tertiary referral center for laparoscopic gynecologic surgery at the University Hospitals of Strasbourg, France.


A 29-year-old woman with dysmenorrhea, constipation, and cyclic diarrhea and two sigmoid endometriotic lesions evident at colonoscopy.


The conservative surgical strategy, possible in cases of benign lesions such as endometriosis, consists of dividing the mesentery close to the digestive tract to preserve the vascular-lymphatic vessels and the surrounding sympathetic and parasympathetic nerves. The less invasive approach consists of natural orifice specimen extraction via the transanal route.


The postoperative course was favorable. The conservative technique enables preservation of the superior rectal vessels, which contribute to 80% of the vascularization of the rectum, to maintain the best vascularization, essential for intestinal anastomosis. Transanal specimen extraction maximizes the benefits of laparoscopy by sparing the abdominal wall from incision and its associated complications.


A conservative surgical approach should be used in segmental bowel resection for treatment of endometriosis. Moreover, the segmental bowel resection can be safely performed with transanal specimen extraction, with great advantages for the patient.



Eur J Obstet Gynecol Reprod Biol. 2013 Jul;169(2):360-5.

The effects of ulipristal on Bax/Bcl-2, cytochrome c, Ki-67 and cyclooxygenase-2 expression in a rat model with surgically induced endometriosis.

Huniadi CA1Pop OLAntal TAStamatian F.




To evaluate the effect of ulipristal on Bax/Bcl-2, cytochrome C, Ki-67 and cyclooxygenase-2 expression in surgically induced endometriosis in a rat model.


We conducted a prospective, randomized, controlled, experimental study at the Experimental Research Center of the Iuliu Hatieganu University of Medicine and Pharmacy in Cluj-Napoca, Romania. Endometriosis was induced in 40 female Wistar albino rats by transplanting two autologous fragments of uterine horn onto bowel mesentery. After a 4-week induction period, we formed two groups: the first group was treated with ulipristal (UPA+) for 8 weeks, while the second group was treated only with the vehicle used for ulipristal (UPA-). We measured the volumes and masses of the implants both before and after treatment. A pathologist examined the sections microscopically for histological hallmarks of endometriosis. Immunostaining for Bax/Bcl-2, cytochrome C, Ki-67 and cyclooxygenase-2 (COX-2) was assessed in both groups.


Ulipristal reduced the average implant volume and mass, indicating that the drug is effective (P=0.01). The treatment induced a greater than 50% reduction in the volume and mass of endometrial implants, and the histological findings correspond to this result. The overall Bax positivity rate was higher in the group treated with ulipristal (42.37% vs. 21.05% for UPA+ and UPA-, respectively) (P=0.0062). The overall Bcl-2 positivity rate was smaller in the group treated with ulipristal (15% vs. 40% for UPA+ and UPA-, respectively) (P=0.0593). The cytochrome C global positivity rate was 5% in the UPA- group and increased to 50% in the UPA+ treatment group (P<0.0001). The COX-2 positivity rate decreased from 75% in the UPA- treatment group to 10% in the UPA+ treatment group (P<0.0001) and the Ki67 positivity rate also decreased from 55% in the UPA- group to 10% in the UPA+ treatment group (P<0.0002).


Treatment with ulipristal contributed to the regression and atrophy of endometriotic lesions in rats. The immunohistochemical expression profiles of Bax/Bcl-2 and cytochrome C revealed a pro-apoptotic effect of ulipristal. We also observed a reduced cellular proliferation, indicated by a decrease in Ki-67 expression and an anti-inflammatory effect, shown by a decrease in COX-2 expression after treatment with ulipristal.



Int J Mol Med. 2013 Jul;32(1):67-78.

Hexane extract of aged black garlic reduces cell proliferation and attenuates the expression of ICAM-1 and VCAM‑1 in TNF-α-activated human endometrial stromal cells.

Kim KH1Park JKChoi YWKim YHLee ENLee JRKim HSBaek SYKim BSLee KSYoon S.



Increasing evidence indicates the potentially crucial roles of intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) in the pathological process underlying endometriosis. The present study aimed to investigate the effects of a hexane extract of aged black garlic (HEABG) on the proliferation and expression of ICAM-1 and VCAM-1 in tumor necrosis factor-α (TNF-α)-activated human endometrial stromal cells (HESCs) isolated from patients with endometriosis. HESCs were isolated from endometriotic tissues obtained from women with advanced endometriosis who underwent laparoscopic surgery for ovarian endometrioma (n=18). Cell proliferation and cell cycle analysis were assessed by WST-1 assay and flow cytometry, respectively. The expression of ICAM-1 and VCAM-1 was measured by flow cytometry, immunofluorescence staining, immunoblotting and quantitative reverse transcriptase-PCR. The secretion of interleukin-6 (IL-6) was determined by enzyme-linked immunosorbent assay (ELISA). The activation of nuclear factor-κB (NF-κB) and activator protein-1 (AP-1) was detected by electrophoretic mobility shift assay (EMSA) and the activation of c-Jun N-terminal kinase (JNK), extracellular signal-regulated kinase (ERK) and p38 MAPK was analyzed by immunoblotting. Cell proliferation and cell cycle progression were significantly suppressed by HEABG in the TNF-α-induced HESCs through the inhibition of the ERK and JNK signaling pathways. Remarkably, the treatment of the HESCs with HEABG potently suppressed the TNF-α-induced ICAM-1 and VCAM-1 transcript and protein expression by inhibiting the activation of NF-κB and AP-1 transcription factors. Our results suggest that HEABG may be effective in the prevention and treatment of endometriosis in humans.



PLoS One. 2013 Apr 19;8(4):e62370.

Peritoneal fluid reduces angiogenesis-related microRNA expression in cell cultures of endometrial and endometriotic tissues from women with endometriosis.

Braza-Boïls A1Gilabert-Estellés JRamón LAGilabert JMarí-Alexandre JChirivella MEspaña FEstellés A.



Endometriosis, defined as the presence of endometrium outside the uterus, is one of the most frequent gynecological diseases. It has been suggested that modifications of both endometrial and peritoneal factors could be implicated in this disease. Endometriosis is a multifactorial disease in which angiogenesis and proteolysis are dysregulated. MicroRNAs (miRNAs) are small non-coding RNAs that regulate the protein expression and may be the main regulators of angiogenesis. Our hypothesis is that peritoneal fluid from women with endometriosis could modify the expression of several miRNAs that regulate angiogenesis and proteolysis in the endometriosisdevelopment. The objective of this study has been to evaluate the influence of endometriotic peritoneal fluid on the expression of six miRNAs related to angiogenesis, as well as several angiogenic and proteolytic factors in endometrial and endometriotic cell cultures from women with endometriosis compared with women without endometriosis.


Endometrial and endometriotic cells were cultured and treated with endometriotic and control peritoneal fluid pools. We have studied the expression of six miRNAs (miR-16, -17-5p, -20a, -125a, -221, and -222) by RT-PCR and protein and mRNA levels of vascular endothelial growth factor-A, thrombospondin-1, urokinase plasminogen activator and plasminogen activator inhibitor-1 by ELISA and qRT-PCR respectively.


Control and endometriotic peritoneal fluid pools induced a significant reduction of all miRNAs levels in endometrial and endometriotic cell cultures. Moreover, both peritoneal fluids induced a significant increase in VEGF-A, uPA and PAI-1 protein levels in all cell cultures without significant increase in mRNA levels. Endometrial cell cultures from patients treated with endometriotic peritoneal fluid showed lower expression of miRNAs and higher expression of VEGF-A protein levels than cultures from controls. In conclusion , this “in vitro” study indicates that peritoneal fluid from women with endometriosis modulates the expression of miRNAs that could contribute to the angiogenic and proteolytic disequilibrium observed in this disease.



J Reprod Immunol. 2013 Jun;98(1-2):1-9.

Chemokines in the pathogenesis of endometriosis and infertility.

Borrelli GM1Carvalho KIKallas EGMechsner SBaracat ECAbrão MS.



Endometriosis is a chronic benign disease that affects women of reproductive age causing abdominal pain and infertility. Its pathogenesis remains obscure despite all the research conducted over the past 100 years. However, there is a consensus among the specialists that the basis of its pathophysiology would be multifactorial. Many publications have demonstrated that chemokines are somehow associated with the development of endometriosis and infertility. In this study, we reviewed all PubMed literature using MeSH terms “chemokines” and “endometriosis” as well as “chemokines” and “female infertility” to establish what we know and what we do not yet know about this relationship.



Hum Reprod. 2013 Aug;28(8):2140-5.

Prospective assessment of the impact of endometriomas and their removal on ovarian reserve and determinants of the rate of decline in ovarian reserve.

Uncu G1Kasapoglu IOzerkan KSeyhan AOral Yilmaztepe AAta B.




Do the presence of endometriomas and their laparoscopic excision lead to a decrease in ovarian reserve as assessed by serum anti-Müllerian hormone (AMH) levels?


Both the presence and excision of endometriomas cause a significant decrease in serum AMH levels, which is sustained 6 months after surgery.


No previous comparison of serum AMH levels between women with and without endometrioma has been reported. However, studies have suggested a decline in serum AMH levels 1-3 months after endometrioma excision but long-term data are needed.


A prospective cohort study including 30 women with endometrioma >2 cm were age matched with 30 healthy women without ovarian cysts.


Women with endometrioma underwent laparoscopic excision with the stripping technique. Serum AMH level and antral follicle count (AFC) were determined preoperatively, 1 and 6 months after surgery. Correlation analyses were undertaken in order to identify determinants of surgery-related change in ovarian reserve.


Compared with controls at baseline, women with endometrioma had lower AMH levels (4.2 ± 2.3 versus 2.8 ± 2.2 ng/ml, respectively, P = 0.02) and AFC (14.7 ± 4.1 versus 9.7 ± 4.8, respectively, P < 0.01). Serum AMH levels were further decreased 6 months after surgery (2.8 ± 2.2 versus 1.8 ± 1.3 ng/ml, P = 0.02), while AFC remained unchanged (9.7 ± 4.8 versus 10.4 ± 4.2, P = 0.63). The rate of decline in AMH was not correlated with age, laterality of endometrioma, cyst diameter or the number of primordial follicles on the surgical specimens. The preoperative serum AMH level was positively correlated with the rate of decline in serum AMH after surgery (r = 0.47, P = 0.02).


The absence of a non-treated group of women with endometriomas as a further control prevents comment on the presence of a progressive decline in ovarian reserve related to endometrioma per se. The sample size may be too small for detection of factors correlated with the extent of ovarian damage.


While the findings are mostly in agreement with previous studies, the present study is the first to show that the presence of endometrioma per se is associated with a decrease in ovarian reserve. The extent of surgery-related decline in ovarian reserve is not predictable using preoperative or perioperative factors. It may be prudent to measure AMH levels preoperatively and delay/avoid surgical excision as far as is possible if subsequent fertility is a concern. Additional studies are required to further investigate whether the endometrioma-related decline in ovarian reserve per se is progressive in nature and whether it exceeds the surgery-related decline.


This study was funded by the Research Fund of the Uludag University School of Medicine. The authors have no conflict of interest associated with this study.



PLoS One. 2013 Apr 23;8(4):e61690.

In vitro effects of a small-molecule antagonist of the Tcf/ß-catenin complex on endometrial and endometriotic cells of patients with endometriosis.

Matsuzaki S1Darcha C.




Our previous studies suggested that aberrant activation of Wnt/ß-catenin signaling might be involved in the pathophysiology of endometriosis. We hypothesized that inhibition of Wnt/ß-catenin signaling might result in inhibition of cell proliferation, migration, and/or invasion of endometrial and endometriotic epithelial and stromal cells of patients with endometriosis.


The aim of the present study was to evaluate the effects of a small-molecule antagonist of the Tcf/ß-catenin complex (PKF 115-584) on cell proliferation, migration, and invasion of endometrial and endometriotic epithelial and stromal cells.


One hundred twenty-six patients (78 with and 48 without endometriosis) with normal menstrual cycles were recruited. In vitro effects of PKF 115-584 on cell proliferation, migration, and invasion and on the Tcf/ß-catenin target genes were evaluated in endometrial epithelial and stromal cells of patients with and without endometriosis, and in endometrial and endometriotic epithelial and stromal cells of the same patients.


The inhibitory effects of PKF 115-584 on cell migration and invasion in endometrial epithelial and stromal cells of patients with endometriosis prepared from the menstrual phase were significantly higher than those of patients without endometriosis. Levels of total and active forms of MMP-9 were significantly higher in epithelial and stromal cells prepared from menstrual endometrium in patients with endometriosis compared to patients without endometriosis. Treatment with PKF 115-584 inhibited MMP-9 activity to undetectable levels in both menstrual endometrial epithelial and stromal cells of patients with endometriosis. The number of invasive cells was significantly higher in epithelial and stromal cells of endometriotic tissue compared with matched eutopic endometrium of the same patients. Treatment with PKF 115-584 decreased the number of invasive endometriotic epithelial cells by 73% and stromal cells by 75%.


The present findings demonstrated that cellular mechanisms known to be involved in endometriotic lesion development are inhibited by targeting the Wnt/β-catenin pathway.



Hinyokika Kiyo. 2013 Mar;59(3):171-4.

A case of endosalpingiosis in submucosa of the urinary bladder.

Mishima T1Harada JKawa GOkada T.



A 39-year-old woman showed thickening of the bladder wall on magnetic resonance imaging (MRI). Since transurethral resection to the lesion revealed that the histological structure of the lesion was compatible with that of the fallopian tube and endometrium, we considered that the tumor was derived from müllerian tissue. Subsequently, partial cystectomy was performed to remove the tumor. Immunohistochemical examination indicated a diagnosis of endosalpingiosis involving endometriosis. The concept of endosalpingiosis was proposed in 1930, and only 9 cases of urinary bladder endosalpingiosis have been reported worldwide. Surgical procedures such as transurethral resection and partial cystectomy were performed in all reported cases. None of the reported cases, including the present case, showed recurrence.




Obstet Gynecol Int. 2013;2013:879618.

Gene expression of leptin and long leptin receptor isoform in endometriosis: a case-control study.

Nácul AP1Lecke SBEdelweiss MIMorsch DMSpritzer PM.



In this study, leptin/BMI ratio in serum and peritoneal fluid and gene expression of leptin and long form leptin receptor (OB-RL) were assessed in eutopic and ectopic endometria of women with endometriosis and controls. Increased serum leptin/BMI ratio was found in endometriosis patients. Leptin and OB-RL gene expression was significantly higher in ectopic versus eutopic endometrium of patients and controls. A positive, significant correlation was observed between leptin and OB-RL transcripts in ectopic endometria and also in eutopic endometria in endometriosis and control groups. A negative and significant correlation was found between OB-RL mRNA expression and peritoneal fluid leptin/BMI ratio only in endometriosis. These data suggest that, through a modulatory interaction with its active receptor, leptin might play a role in the development of endometrial implants.




Practitioner. 2013 Mar;257(1759):15-7, 2.

Diagnosis and treatment of ectopic pregnancy.

Epee-Bekima M1Overton C.



The most common site of localisation of an ectopic pregnancy is the fallopian tube. Rarely an ectopic pregnancy can be found in the ovary, a caesarean section scar, the abdomen or the cervix. Risk factors are previous ectopic pregnancy, PID, endometriosis, previous pelvic surgery, the presence of a coil and infertility. However, a third of women with an ectopic pregnancy have no known risk factors. NICE recommends a low threshold for offering a pregnancy test to women of childbearing age when they attend the surgery. Symptoms and signs appear when the tube starts to tear. When the tube ruptures, the woman will quickly become unwell and haemodynamically unstable because of rapid intra-abdominal blood loss. The most common symptoms of ectopic pregnancy are pelvic or abdominal pain, amenorrhoea, missed period or abnormal period and vaginal bleeding. A positive diagnosis of a urinary tract infection or gastroenteritis does not exclude an ectopic pregnancy. Signs of suspected ectopic pregnancy include pelvic, abdominal, adnexal or cervical motion tenderness, rebound tenderness and abdominal distension. Women who are haemodynamically unstable, or in whom there is significant concern about the degree of pain or bleeding, should be referred directly to A&E, irrespective of the result of the pregnancy test. Stable patients with bleeding who have pain or a pregnancy of six weeks gestation or more or a pregnancy of uncertain gestation should be referred immediately to an early pregnancy assessment (EPA) service, or out-of-hours gynaecology service if the EPA service is not available. Diagnosis is confirmed by transvaginal ultrasound scan to identify the location of the pregnancy.




Practitioner. 2013 Mar;257(1759):19-22, 2-3.

Optimising the management of patients with infertility.

Child T1.



The main causes of infertility are female factor (anovulation, tubal damage, endometriosis and ovarian failure), male factor (low or absent numbers of motile sperm in the ejaculate, and erectile dysfunction), or unexplained infertility. More than 80% of couples will conceive within one year if the woman is aged under 40 and they have regular sexual intercourse. Of those who fail to conceive in the first year, around half will do so in the second year, giving a cumulative pregnancy rate > 90%. A woman of reproductive age who has not conceived after a year of regular sexual intercourse, and has no known cause of infertility, should be offered referral for further clinical assessment and investigation with her partner. Women who have a BMI > or = 30 are likely to take longer to conceive. Those with a BMI < 19 who have irregular or absent menstruation should be advised that putting on weight is likely to improve their chance of conception. The best test of ovulation is an appropriately timed mid-luteal serum progesterone level. Women with irregular or absent menstrual cycles should be offered a blood test to measure serum gonadotrophin levels (FSH and LH). Women with no known comorbidities should be screened for tubal occlusion. Those who are thought to have comorbidities should be offered laparoscopy and dye testing.



Eur J Med Res. 2013 May 1;18:13.

Endometriosis of the lung: report of a case and literature review.

Huang H1Li CZarogoulidis PDarwiche KMachairiotis NYang LSimoff MCelis EZhao TZarogoulidis KKatsikogiannis NHohenforst-Schmidt WLi Q.



This paper reports a case of endometriosis of the lung in a 29-year-old woman with long-term periodic catamenial hemoptysis. A chest computed tomography image obtained during menstruation revealed a radiographic opaque lesion in the lingular segment of the left superior lobe. During bronchoscopy, bleeding in the mucosa of the distal bronchus of the lingular segment of the left superior lobe was observed. Histopathology subsequent to an exploratory thoracotomy confirmed the diagnosis of endometriosis of the left lung. The 2-year follow-up after lingular lobectomy of the left superior lobe showed no recurrence or complications.



Gynecol Obstet Invest. 2013;76(1):32-7.

Association between genetic variants of the VEGFR-2 gene and the risk of developing endometriosis in Northern Chinese Women.

Kang S1Shi YYLi YWang NLu YCZhou RMZhao XW.




To investigate the association of tag single nucleotide polymorphisms (SNPs) in the vascular endothelial growth factor receptor 2 (VEGFR-2) gene with susceptibility to endometriosis.


This study comprised 571 patients with endometriosis and 580 women in the control group. Five tag SNPs in the VEGFR-2 gene were selected using a Haploview program, and those SNPs were genotyped by a method of polymerase chain reaction and ligase detection reaction.


Statistical results show that there was a significant difference in the genotype and allele distribution of the 1192C/T polymorphism between the disease group and the control group (p = 0.041 and 0.017). The women carrying the T allele (C/T+T/T genotype) had a lower risk of developing endometriosis compared with the women with the C/C genotype (OR 0.75, 95% CI 0.57-0.99). There was no significant difference in the allele and genotype distribution of four other tag SNPs (1719T/A, +31C/T, IVS25-92A/G and IVS6+​54C/T) between the disease group and the control group (all p > 0.05).


Our results suggested that the 1192C/T polymorphisms on the VEGFR-2 gene might affect the risk of developing endometriosis in Northern Chinese women of Han ethnicity.


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