Medicine (Baltimore). 2018 Feb;97(8):e9536. doi: 10.1097/MD.0000000000009536.
Diagnostic accuracy of magnetic resonance imaging, transvaginal, and transrectal ultrasonography in deep infiltrating endometriosis.
To determine the diagnostic accuracy of pelvic magnetic resonance imaging (MRI), transvaginal sonography (TVS), and transrectal sonography (TRS) in diagnosis of deep infiltrating endometriosis (DIE).This diagnostic accuracy study was conducted during a 2-year period including a total number of 317 patients with signs and symptoms of endometriosis. All the patients were evaluated by pelvic MRI, TVS, and TRS in the same center. The criterion standard was considered to be the laparoscopy and histopathologic examination.Of 317 patients being included in the present study, 252 tested positive for DIE. The sensitivity, specificity, positive predictive value, and negative predictive value of TVS was found to be 83.3%, 46.1%, 85.7%, and 41.6%, respectively. These variables were 80.5%, 18.6%, 79.3%, and 19.7% for TRS and 90.4%, 66.1%, 91.2%, and 64.1% for MRI, respectively. MRI had the highest accuracy (85.4%) when compared to TVS (75.7%) and TRS (67.8%). The sensitivity of TRS, TVS, and MRI in uterosacral ligament DIE was 82.8%, 70.9%, and 63.6%, respectively. On the contrary, specificity had a reverse trend, favoring MRI (93.9%, 92.8%, and 89.8% for TVS and TRS, respectively).The results of the present study demonstrated that TVS and TRS have appropriate diagnostic accuracy in diagnosis of DIE comparable to MRI.
Oman Med J. 2018 Jan;33(1):72-75. doi: 10.5001/omj.2018.14.
Fine-needle Aspiration Cytology of Abdominal Wall Endometriosis: A Meaningful Adjunct to Diagnosis.
Fine-needle aspiration cytology (FNAC) is a simple, non-invasive diagnostic modality which can be performed with ease on any superficially palpable lesion. Surgical scar endometriosis is a rare entity which presents as an abdominal lump in women of reproductive age. It is often a diagnostic pitfall for clinicians due to its nonspecific symptoms. It displays characteristic morphology, which needs to be identified and recognized by a cytopathologist for accurate diagnosis. FNAC can be used as a key diagnostic tool in cases of abdominal wall mass for appropriate patient management, thereby avoiding unnecessary diagnostic procedures. Here, we report the case of a 35-year-old woman who presented with an abdominal lump where FNAC played a vital role in the patient’s management.
Hum Reprod Update. 2018 Feb 15. doi: 10.1093/humupd/dmy004. [Epub ahead of print]
The effect of pregnancy on endometriosis-facts or fiction?
It is not uncommon for women with endometriosis to be advised that becoming pregnant might be a useful strategy to manage their symptoms and reduce disease progression. Consequently, many women diagnosed with endometriosisand motivated to become pregnant, may also have expectations regarding improvement of symptoms and the disease. However, study results on the effect of pregnancy on endometriosis are controversial and pregnancy in women with endometriosis is not always associated with improved symptoms. Moreover, there is increasing evidence that endometriosis may interfere with a successful pregnancy outcome.
OBJECTIVE AND RATIONALE:
The objective was to evaluate the evidence on whether pregnancy and lactation has a beneficiary effect on growth characteristics and symptoms of endometriosis diagnosed prior to pregnancy.
A search for articles containing keywords related to pregnancy and endometriosis was performed via PubMed. Manuscripts dealing with a potential effect of pregnancy on endometriosis were systematically reviewed. We included English, French and German language publications on human studies from 1966 to May 2017. Bibliographies of these manuscripts were searched for further relevant literature.
Five small observational studies were identified concerning the longitudinal development of endometriotic lesions during and after pregnancy, four of medium and one of low quality. Eleven publications reported measurements of endometriomas during pregnancy and the postpartum period (the five studies just mentioned and six case reports). Another 22 case reports/small case series (maximum of five cases), six studies on histology of endometriotic lesions in pregnancy, plus eight studies on the role of pregnancy in initial development and recurrence of endometriosis were included. Few studies of very limited quality are available to evaluate the effect of pregnancy and the postnatal period on the development of endometriosis. The development of endometriosis is variable and there is no evidence that pregnancy can be expected to generally reduce the size and number of endometriotic lesions. Growth and structural changes of lesions during pregnancy may occur with decidualization. Results on the association between pregnancy and symptoms of endometriosis are controversial and strongly biased.
Available data on the development of endometriosis during and after pregnancy show fewer beneficial effects than previously reported. Therefore, women aiming for pregnancy on the background of endometriosis should not be told that pregnancy may be a strategy for managing symptoms and reducing progression of the disease.
Radiol Med. 2018 Feb 23. doi: 10.1007/s11547-018-0862-y. [Epub ahead of print]
Biopsy is not necessary for the diagnosis of soft tissue hemangiomas.
To describe the clinical and ultrasonography (US) findings of soft tissue hemangiomas, and to compare with the results of histologic diagnosis after US-guided biopsy.
METHOD AND MATERIALS:
We retrospectively studied the files of 97 patients (48 female, 49 male; mean age, 34 years; range 4-84 years) with soft tissue hemangiomas diagnosed from 2004 to 2011. Mean follow-up was 9 years (range 7-13 years). Clinical presentation included intermittent mild pain associated with a soft tissue swelling/palpable mass in all patients, chronic pain and increased local heat in 29 patients, local swelling and decreased range of motion of the adjacent joint in 45 patients, and all the above symptoms in 23 patients. B-mode and color Doppler US evaluation included the site, location, size, shape, margins, presence of calcifications, echo structure and echogenicity. All patients had US-guided biopsy for histologic analysis.
US-guided biopsy and histology confirmed the diagnosis of soft tissue hemangioma in 92 of the 97 lesions (94.8%). Histologic examination of the remaining five lesions showed nodular fasciitis (two lesions), endometriosis (one lesion), hemangioendothelioma (two lesions); US of these lesions showed variable size, irregular margins, and deep-seated location. Histologically documented soft tissue hemangiomas were most commonly superficial (74 lesions) and arteriovenous (45 lesions). Shape was most commonly oval (fusiform), margins were most commonly not well defined (irregular, hazing but circumscribed), phleboliths were more common in deep-seated lesions, echo structure was heterogeneous, and echogenicity was most commonly hyperechogen and involuting.
Clinical presentation and typical B-mode and color Doppler US findings are adequate for the diagnosis of soft tissue hemangiomas without the need for biopsy and histologic analysis. If any clinical or US doubt, an US-guided biopsy should be performed.
Clin Pharmacokinet. 2018 Feb 23. doi: 10.1007/s40262-018-0629-6. [Epub ahead of print]
Population Pharmacokinetics of Elagolix in Healthy Women and Women with Endometriosis.
Elagolix is a novel, orally active, non-peptide, competitive gonadotropin-releasing hormone (GnRH) receptor antagonist in development for the management of endometriosis with associated pain and heavy menstrual bleeding due to uterine fibroids. The pharmacokinetics of elagolix have been well-characterized in phase I studies; however, elagolix population pharmacokinetics have not been previously reported. Therefore, a robust model was developed to describe elagolix population pharmacokinetics and to evaluate factors affecting elagolix pharmacokinetic parameters.
The data from nine clinical studies (a total of 1624 women) were included in the analysis: five phase I studies in healthy, premenopausal women and four phase III studies in premenopausal women with endometriosis.
Elagolix population pharmacokinetics were best described by a two-compartment model with a lag time in absorption. Of the 15 covariates tested for effect on elagolix apparent clearance (CL/F) and/or volume of distribution only one covariate, organic anion transporting polypeptide (OATP) 1B1 genotype status, had a statistically significant, but not clinically meaningful, effect on elagolix CL/F.
Elagolix pharmacokinetics were not affected by patient demographics and were similar between healthy women and women with endometriosis. Clinical Trial Registration
J Reprod Immunol. 2018 Feb 6;126:32-38. doi: 10.1016/j.jri.2018.02.003. [Epub ahead of print]
Treg and NK cells related cytokines are associated with deep rectosigmoid endometriosis and clinical symptoms related to the disease.
The aim of this study was to evaluate Treg and NK cells related cytokines in deep infiltrating endometriosis lesions and its relationship with clinical symptoms of the disease. mRNA expression of Transforming Growth Factor Beta (TGFB), Interleukin (IL)10, Interferon Gamma (IFNG), IL7, and IL15 was analyzed by Real-Time PCR in eutopic endometrium and rectosigmoid lesions from 11 women with deep infiltrating endometriosis and in eutopic endometrium from 11 healthy women. IL10, IFNG, and IL7 expression was significantly higher in endometriotic bowel lesions than in eutopic endometrium from women with endometriosis. IL10 and TGFB expression was significantly higher in endometriotic bowel lesions than in eutopic endometrium from healthy women. In addition, TGFB and IL15 levels correlated positively with deep dyspareunia and cyclic dyschezia, respectively, while IL7 levels correlated negatively with dysmenorrhea. Deep infiltrating rectosigmoid endometriosis displays alterations in Treg and NK cells related cytokine, and TGFB, IL7 and IL15 expression is related with dyspareunia, dysmenorrhea and cyclic dyschezia, respectively, in patients with the disease.
Int J Surg Case Rep. 2018 Feb 14;44:75-77. doi: 10.1016/j.ijscr.2018.02.012. [Epub ahead of print]
Intestinal obstruction caused by endometriosis: Endoscopic stenting and expedited laparoscopic resection avoiding stoma. A case report and review of the literature.
Endometriosis is the growth of endometrium outside the uterine cavity. In 5-15% of cases the disease can affect the colon and small bowel, causing complete obstruction and requiring resection in about 1% of cases.
We describe a case of sigmoid obstruction due to endometriosis in a 38 years old woman with personal history of endometriosis. She was admitted for abdominal pain and constipation. The patient was treated with endoscopic stenting and subsequent laparoscopic sigmoidectomy.
Bowel obstruction caused by endometriosis is a rare event. Its diagnosis can thus be a clinical and radiological challenge but it may be suspected in all young woman with colonic obstruction. At present, the management of endometriosis is an integrate approach of both medical and surgical therapy. In case of irreversible colonic obstruction surgery is mandatory. The treatment of choice is usually an emergency procedure (either Hartmann procedure or resection and anastomosis with stoma placement). This approach entails all the risks related to emergency procedures and can have important psychological and biological drawbacks.
Endoscopic prosthesis placement as bridge to surgery is a feasible therapeutic strategy in colonic obstruction due to endometriosis. It brings about all the advantages of an expedited one step laparoscopic surgical procedure. Laparoscopic elective resection has a lower rate of stoma placement and has a postoperative pregnancy rate grater than open surgery.
Copyright © 2018. Published by Elsevier Ltd.
J Pak Med Assoc. 2018 Feb;68(2):224-230.
Association of TP53 codon 72 polymorphism in women suffering from endometriosisfrom Lahore, Pakistan.
To investigate TP53 gene codon 72 polymorphism in women with endometriosis and compare it with healthy samples.
This case-control study was carried out at Jinnah Hospital, Services Hospital and Sheikh Zayed Hospital, Lahore, Pakistan, from 2014 to 2016, and comprised patients with endometriosis and healthy controls. SPSS 21 was used for statistical analysis.
Of the 176 participants, 88(50%) were healthy controls and 88(50%) were endometriosis patients. The observed genotype frequencies for controls and patients were 14(15.9%) and 31(35.3%) for proline/proline, 46(52.3%) and 35(39.8%) for proline/arginine, and 28(31.8%) and 22(25%) for arginine/arginine, respectively. The association of different genotypes was not significant in patients with moderate-to-severe endometriosis (p=0.574). The presence of pro/pro genotype enhanced the chances/odds of getting the disease (p<0.05). However, the risk further increased with the advancement of age, particularly in the 27-46 age group (p<0.05).
In Pakistani women the association of TP53 gene codon 72 arginine/proline polymorphism was present..
Asian Pac J Cancer Prev. 2018 Feb 26;19(2):509-512.
Does Endometriosis Hinder Successful Ovarian Debulking Surgery?
Endometriosis has a significant effect on many aspects of women’s lives, also increasing the risk of ovarian cancer. Although endometriosis is considered as a benign condition, it sometimes behaves like cancer.
All medical records of epithelial ovarian cancer patients during January 2011 to December 2016 were reviewed. Recurrent cases were excluded. Data collected included age at diagnosis, parity, marital status, familial history of cancer, menopausal status, weight, height, smoking histroy, contraception, CA 125 level, result of surgery and pathological report.
One hundred and seventy-two medical records of patients with epithelial ovarian cancer (EOC) were included. Average age at diagnosis was 52.3 years. Epithelial ovarian cancer coexisting with endometriosis (EAOC) was found in nearly one-fifth of cases. Nullipara and smoking were associated with 2.3 and 8.3 fold higher risk of EAOC development (aOR 2.349, 95%CI 1.012-5.451; aOR 8.26, 95%CI 1.234-55.278; respectively). Age, familial history of cancer and coexistence with endometriosis were factors related to surgical outcome. More of EAOC group had optimal surgery compared to the non-EAOC group (61.3% and 41.8%) with statistical significance.
Younger age, familial history of cancer and coexistence of endometriosis were factors related to optimal surgery. Success of optimal surgery is greater in EAOC than in non-EAOC patients. Coexistence of endometriosis does not hinder successful ovarian cancer debulking surgery.
Chin Med J (Engl). 2018 Mar 5;131(5):559-566. doi: 10.4103/0366-6999.226070.
Identification of Circular RNAs as a Novel Biomarker for Ovarian Endometriosis.
Endometriosis is a challenging disease with symptoms such as dysmenorrhea and infertility. However, its etiology is still vague and there is still no effective markers or treatment. This study aimed to profile the circular RNAs (circRNAs) expressed in eutopic endometrium from patients with ovarian endometriosis and explore potential clues to the pathogenesis of endometriosis, providing an evidence for clinical diagnosis and treatment.
A total of 63 clinical samples, including control endometrium (n = 22) and eutopic endometrium (n = 41), were collected from Peking Union Medical College Hospital between May 1, 2016, and December 31, 2016. Of them, four samples in each group were used for circRNA microarray. Then, four upregulated circRNAs were screened out for quantitative real-time polymerase chain reaction (qRT-PCR) validation. After that, bioinformatics analysis was performed to predict miRNAs targeted by validated circRNAs and investigate the circRNA-miRNA-mRNA interactions.
Among 88 differentially expressed circRNAs, 11 were upregulated and 77 were downregulated in eutopic endometrium of patients with endometriosis. qRT-PCR validation results for two upregulated circRNAs (circ_0004712 and circ_0002198) matched the microarray results. The area under the receiver operating characteristic curve of circ_0002198 for distinguishing ovarian endometriosis was 0.846 (95% confidence interval [CI]: 0.752-0.939; P < 0.001) while that of circ_0004712 was 0.704 (95% CI: 0.571-0.837; P = 0.008). On the basis of target prediction, we depicted the molecular interactions between the identified circRNAs and their dominant target miRNAs, as well as constructed a circRNA-miRNA-mRNA network.
This study provides evidence that circRNAs are differentially expressed between eutopic and normal endometrium, which suggests that circRNAs are candidate factors in the activation of endometriosis. circ_0002198 and circ_0004712 may be potential novel biomarkers for the diagnosis of ovarian endometriosis.
Radiol Case Rep. 2017 Jul 24;12(4):741-745. doi: 10.1016/j.radcr.2017.06.009. eCollection 2017 Dec.
Massive endometrioma presenting with dyspnea and abdominal symptoms.
An abdominal mass may present with a myriad of symptoms resulting from compression of surrounding organs. A major clinical challenge with practical implications is accurate preoperative identification of the origin of the mass. Here, we present the case of a 29-year-old female patient with abdominal distension and shortness of breath for approximately 6 weeks before presentation. A large abdominal mass compressing the surrounding organs was observed on abdominal x-ray and computed tomography of the abdomen and pelvis. Preoperative imaging was unable to identify the organ of origin; pathologic and histologic analyses of the tumor ultimately identified a rare, massive intra-abdominal endometrioma, freely floating within the peritoneum and fed by an omental blood supply. This case highlights the importance of considering an atypical presentation of endometriosis in women of reproductive age with abdominal complaints.
Harefuah. 2018 Feb;157(2):91-94.
DYSMENORRHEA – ITS PREVALENCE, CAUSES, INFLUENCE ON THE AFFECTED WOMEN AND POSSIBLE TREATMENTS.
Dysmenorrhea is a common condition among young menstruating women. It is defined as menstrual pains, which sometimes, may be so severe, as to completely cripple the affected woman in every aspect of her daily function. Dysmenorrhea may further cause female infertility problems. This disease is divided into two forms: primary – where no accompanying pelvic pathology is found, and secondary – where pelvic pathology is demonstrated. The most prevalent cause of the latter form is endometriosis. Treatment comprises of medication, such as NSAIDs or various hormonal preparations or several methods of complementary medicine, as well as surgery. Generally, medical and complementary forms of treatment have been found effective in alleviating the pain, while surgery was found effective in treating infertility. Dysmenorrhea, in general, and endometriosis, in particular, has a further immense financial burden on society – both in terms of medical cost, as well as absence from studies or work by young women. To date, no absolute effective treatment, in terms of pain prevention or long standing fertility preservation, has been found.
Int J Surg Pathol. 2018 Feb 1:1066896918758916. doi: 10.1177/1066896918758916. [Epub ahead of print]
Umbilical Lesions: Clinicopathologic Features of 99 Tumors.
Umbilical lesions are rare, and can be benign or malignant. This retrospective study was conducted to assess the epidemiological, clinical, and histologic characteristics of umbilical masses.
Cases of umbilical masses from January 1994 to August 2016 were retrieved from our institution’s pathology databases, and their clinicopathological features were reviewed.
There were a total of 99 cases of umbilical masses, 78 women (78.8%) and 21 men (21.2%). Of these, 59 were malignant (59.6%) and 40 were benign (40.4%). Among the malignant cases, 48 were women with a mean age of 65 years and 11 were men with a mean age of 66 years. All malignant lesions were secondary tumors. Twenty-five patients (42.3%) had a metastatic tumor to the umbilicus with an average of 7 months from the original diagnosis (12 gynecological, 8 pancreatic/gastrointestinal, 2 lymphomas, and a case each of breast, prostate, and melanoma). Of the patients with a benign diagnosis, 30 were women (75%) with a mean age of 52 years and 10 were men (25%) with a mean age of 43 years. The benign lesions included epidermal inclusion cysts (15/40), endometriosis (11/40), lipomas (3/40), neurofibromas (3/40), fibromas (3/40), abscesses (2/40), and 1 case each of tubular apocrine adenoma, serous cystadenoma, and calcified nodule.
The most common metastatic tumors to the umbilicus are from the adjacent organs with the gynecologic tract as the most frequent primary followed by the gastrointestinal system. Primary malignant tumors of the umbilical region are rarely identified in clinical practice.
Gynecol Obstet Invest. 2018 Feb 27. doi: 10.1159/000486335. [Epub ahead of print]
Shifting from Oral Contraceptives to Norethisterone Acetate, or Vice Versa, because of Drug Intolerance: Does the Change Benefit Women with Endometriosis?
Oral contraceptives (OC) and norethisterone acetate (NETA) are among first-line medical therapies for symptomatic endometriosis, but their use is sometimes associated with intolerable side effects. We investigated whether shifting from low-dose OC to NETA (2.5 mg/day), or vice versa, improved tolerability.
Sixty-seven women willing to discontinue their treatment because of intolerable side effects despite good pain relief, were enrolled in a self-controlled study, and shifted from OC to NETA (n = 35) or from NETA to OC (n = 32). The main study outcome was satisfaction with treatment 12 months after the change. Tolerability, pain symptoms, health-related quality of life, psychological status, and sexual functioning were also evaluated.
After treatment change, good tolerability was reported by 37% of participants who shifted to NETA, and by 52% of those who shifted to OC. At 12-month assessment, 51% of women intolerant to OC were satisfied with NETA, and 65% of those intolerant to NETA were satisfied with OC (intention-to-treat analysis). Other study variables did not vary substantially.
In selected endometriosis patients, shifting from OC to NETA, or vice versa, because of side effects, improved tolerability. Better results were observed when substituting NETA with OC rather than the other way round.
© 2018 S. Karger AG, Basel.
J Med Imaging (Bellingham). 2018 Apr;5(2):021213. doi: 10.1117/1.JMI.5.2.021213. Epub 2018 Feb 8.
Feasibility of photoacoustic-guided teleoperated hysterectomies.
Hysterectomies (i.e., surgical removal of the uterus) are the prevailing solution to treat medical conditions such as uterine cancer, endometriosis, and uterine prolapse. One complication of hysterectomies is accidental injury to the ureters located within millimeters of the uterine arteries that are severed and cauterized to hinder blood flow and enable full uterus removal. This work explores the feasibility of using photoacoustic imaging to visualize the uterine arteries (and potentially the ureter) when this imaging method is uniquely combined with a da Vinci® surgical robot that enables teleoperated hysterectomies. We developed a specialized light delivery system to surround a da Vinci® curved scissor tool, and an ultrasound probe was placed externally, representing a transvaginal approach, to receive the acoustic signals. Photoacoustic images were acquired while sweeping the tool across our custom 3-D uterine vessel model covered in ex vivo bovine tissue that was placed between the 3-D model and the fiber, as well as between the ultrasound probe and the 3-D model. Four tool orientations were explored, and the robot kinematics were used to provide tool position and orientation information simultaneously with each photoacoustic image acquisition. The optimal tool orientation produced images with contrast [Formula: see text] and background signal-to-noise ratios (SNRs) [Formula: see text], indicating minimal acoustic clutter from the tool tip. We achieved similar contrast and SNR measurements with four unique wrist orientations explored with the scissor tool in open and closed configurations. Results indicate that photoacoustic imaging is a promising approach to enable visualization of the uterine arteries to guide hysterectomies (and other gynecological surgeries). These results are additionally applicable to other da Vinci® surgeries and other surgical instruments with similar tip geometry.
Gen Thorac Cardiovasc Surg. 2018 Feb 27. doi: 10.1007/s11748-018-0902-5. [Epub ahead of print]
Removal of an endometrioid stromal sarcoma from the inferior vena cava and right atrium.
Entometrioid stromal sarcomas are seen in extra-uterine as well as extra-gonadal sites and have a strong association with endometriosis. Although having better prognosis than other sarcomas, yet these tumors may relapse (whether local or distant) in up to 56% of cases, even as late as 20 years after surgery. We report a case of a 30-year-old female patient with a mass in the inferior vena cava and right atrium which was surgically removed using cardiopulmonary bypass and deep hypothermic circulatory arrest and turned to be an entometrioid stromal sarcoma. The patient gave a history of endometriosis followed by the appearance of a low-grade ovarian endometrioid stromal sarcoma 4 years before the development of the mass in the IVC and right atrium.
Reprod Sci. 2018 Jan 1:1933719118759439. doi: 10.1177/1933719118759439. [Epub ahead of print]
The Relationship of Circular RNAs With Ovarian Endometriosis.
Circular RNAs (circRNAs) are involved in the pathogenesis of many diseases, although their expression pattern and role in endometriosis remains unknown. Therefore, here, we profiled the expression patterns of circRNAs in ovarian ectopic and paired eutopic endometria as well as constructed a circRNA-miRNA-mRNA network. Circular RNA and messenger RNA (mRNA) expression profiles were assessed by a microarray analysis in 4 patients. Quantitative real-time polymerase chain reaction (qRT-PCR) validation of 8 circRNAs and mRNAs was conducted in another 37 patients. We detected 1258 up- and 1061 downregulated circRNAs as well as 1900 up- and 2535 downregulated mRNAs between the ectopic and eutopic endometria. Functional analysis suggested that most differentially expressed mRNAs participate in immune-inflammatory responses and cell cycle regulation. The qRT-PCR validation results for 5 circRNAs ( circ_0004712, circ_0002198, circ_0003570, circ_0008951, and circ_0017248) and 8 mRNAs ( SCN3B, ENTPD1, IL16, BACH2, C3, CKS2, G0S2, and PGRMC1) matched the microarray results. On basis of target prediction, we constructed a circRNA-miRNA-mRNA network. This revealed the primary roles of cancer-related, purine metabolism, glycerophospholipid metabolism, and thyroid hormone signaling pathways in endometriosispathogenesis. This is the first study of circRNA expression patterns in ovarian endometriosis, which suggests that circRNAs are candidate factors in the activation of ovarian endometriosis and are promising diagnostic biomarkers and treatment targets.
Gynecol Obstet Fertil Senol. 2018 Feb 25. pii: S2468-7189(18)30028-X. doi: 10.1016/j.gofs.2018.01.009. [Epub ahead of print]
Definition of endometriosis expert centres.
Chanavaz-Lacheray I1, Darai E2, Descamps P2, Agostini A2, Poilblanc M1, Rousset P1, Bolze PA1, Panel P2, Collinet P2, Hebert T2, Graesslin O2, Martigny H1, Brun JL2, Dechaud H2, Mezan De Malartic C1, Piechon L1, Wattiez A1, Chapron C3, Golfier F4.
The Collège national des gynécologues obstétriciens français (CNGOF), in agreement with the Société de chirurgie gynécologique et pelvienne (SCGP), has set up a commission in 2017 to define endometriosis expert centres, with the aim of optimizing endometriosis care in France.
The committee included members from university and general hospitals as well as private facilities, representing medical, surgical and radiological aspects of endometriosis care. Opinion of endometriosis patients’ associations was obtained prior to writing this work. The final text was presented and unanimously validated by the members of the CNGOF Board of Directors at its meeting of October 13, 2017.
Based on analysis of current management of endometriosis and the last ten years opportunities in France, the committee has been able to define the contours of endometriosis expert centres. The objectives, production specifications, mode of operation, missions and funding for these centres were described. The following missions have been specifically defined: territorial organization, global and referral care, communication and teaching as well as research and evaluation.
Because of its daily impact for women and its economic burden in France, endometriosis justifies launching of expert centres throughout the country with formal accreditation by health authorities, ideally as part of the National Health Plan.
Copyright © 2018 Elsevier Masson SAS. All rights reserved.
Int J Reprod Biomed (Yazd). 2017 Dec;15(12):787-794.
Does laparoscopy still has a role in modern fertility practice?
More than 3 decades after the introduction of in vitro fertilization (IVF) and despite the improved success rates of assisted reproductive technologies, the argument for performing laparoscopy as a part of the infertility workup still stands.
To evaluate the role of laparoscopy±hysteroscopy in diagnosis and management of infertility in our setting in view of modern fertility practice.
MATERIALS AND METHODS:
This case control study was carried out on 600 infertile women subjected to laparoscopy or combined laparoscopy and hysteroscopy at endoscopy unit in Minia University Hospital, Egypt during the period from January 2012 to December 2014.
The causes of infertility as identified by laparoscopy±hysteroscopy were polycystic ovary syndrome (25.1%), tubal factor (30%), uterine cause (4%), and endometriosis (2.7%). No cause was identified in 38.2% of cases. Based on operative findings, women were treated with different options. Expectant management was used in 92 cases (15.3%). Ovulation induction with anti-estrogens or gonadotropins was used in 372 cases (62%). Sixty cases (10%) had intrauterine insemination and sixty four cases (10.7%) underwent in vitro fertilization (IVF) / intracytoplasmic sperm injection (ICSI) treatment. Within 1 yr after laparoscopy, 180 cases achieved pregnancy (30%). The most favorable outcome was recorded in women with unexplained infertility (36.7% of cases got pregnant) followed by women with polycystic ovary syndrome (27.8%). Participants with uterine and tubal infertility factor achieved pregnancy in 25% and 22.8% of cases, respectively. The worst outcome was recorded in women with endometriosis.
Laparoscopy still has an important role in the diagnosis and treatment of infertility.
Int J Reprod Biomed (Yazd). 2017 Dec;15(12):803-806.
Successful pregnancy and live birth after intrauterine administration of autologous platelet-rich plasma in a woman with recurrent implantation failure: A case report.
Platelets contain a significant amount of growth factors that have positive effects on local tissue repair and endometrial receptivity.
Here we present a 45-yr-old woman with primary infertility and two failed in vitro fertilization (IVF) cycles who was candidate to receive donor eggs. Five consecutive frozen-thawed embryo transfer cycles with good quality embryos were performed within 2 yr. With the diagnosis of recurrent implantation failure (RIF), the patient was treated for improving endometrial receptivity with intrauterine administration of autologous platelet-rich plasma (PRP), 24 hr before embryo transfer. The patient gave birth to a healthy baby boy weighing 2350 gr in the cesarean section.
Extensive literature search suggests that this is the ﬁrst successful pregnancy after administration of PRP in a woman with RIF. Local administration of PRP before embryo transfer may play a vital role in successful implantation .
Am J Reprod Immunol. 2018 Mar 1. doi: 10.1111/aji.12839. [Epub ahead of print]
Pleiotropic roles of melatonin in endometriosis, recurrent spontaneous abortion, and polycystic ovary syndrome.
Melatonin is a neurohormone synthesized from the aromatic amino acid tryptophan mainly by the pineal gland of mammals. Melatonin acts as a broad-spectrum antioxidant, powerful free radical scavenger, anti-inflammatory agent, anticarcinogenic factor, sleep inducer and regulator of the circadian rhythm, and potential immunoregulator. Melatonin and reproductive system are interrelated under both physiological and pathological conditions. Oxidative stress, inflammation, and immune dysregulation are associated with the pathogenesis of the female reproductive system which causes endometriosis (EMS), recurrent spontaneous abortion (RSA), and polycystic ovary syndrome (PCOS). Accumulating studies have indicated that melatonin plays pleiotropic and essential roles in these obstetrical and gynecological disorders and would be a candidate therapeutic drug to regulate inflammation and immune function and protect special cells or organs. Here, we systematically review the pleiotropic roles of melatonin in EMS, RSA, and PCOS to explore its pathological implications and treatment potential.
Climacteric. 2018 Mar 1:1-6. doi: 10.1080/13697137.2018.1439913. [Epub ahead of print]
Surgical challenges in the treatment of perimenopausal and postmenopausal endometriosis.
Endometriosis is classically defined as a chronic, recurrent and progressive disease. It is known to be estrogen-dependent, but can still be observed during the peri- and postmenopausal periods. Medical management of endometriosis is palliative symptomatic relief. Surgery when properly and timely performed for the right person may treat endometriosis. However, there is always a risk of possible major or minor surgical complications, as well as loss of some functions due to nerve damage. Management of endometriosis in the woman approaching the end of her reproductive life may require special attention both due to the potential for recurrence and transformation into various endometriosis-associated malignancies.
J Pain. 2018 Feb 26. pii: S1526-5900(18)30085-3. doi: 10.1016/j.jpain.2018.02.005. [Epub ahead of print]
The Long-Term Footprint of Endometriosis: Population-Based Cohort Analysis Reveals Increased Pain Symptoms and Decreased Pain Tolerance at Age 46.
Previous studies have shown increased pain sensitivity in fertile-aged women with endometriosis in response to mechanical stimuli. As yet, population-based studies on the association of endometriosis with pain sensation and pain symptoms in late fertile age are lacking. The main objective of this population-based cohort study was to investigate whether a history of endometriosis is associated with altered pain sensation and musculoskeletal pain symptoms at age 46. Our data is derived from the Northern Finland Birth Cohort 1966, which contains postal questionnaire data (72% response rate) as well as clinical data assessing pressure-pain threshold (PPT) and maximal pain tolerance (MaxPTo). The study population consisted of 284 women with endometriosis and 3390 controls. Our results showed that at age 46 women with a history of endometriosis had a 5.3% lower PPT and 5.1% lower maxPTo compared with controls. The most significant contributors besides endometriosis were anxiety, depression and current smoking status. Women with endometriosis also reported an increased number of pain sites (0 pain sites, 9.6 vs. 17.9%; 5-8 pain sites, 24.8 vs. 19.1%, endometriosis vs. controls respectively, p<0.001), and their pain was more troublesome and intense. The results were adjusted for BMI, smoking, depressive/anxiety symptoms, education and use of hormonal contraceptives. This unique data revealed an altered pain sensation and a greater likelihood of reporting musculoskeletal pain at age 46 among women with a history of endometriosis. The results imply that endometriosis has a long-term footprint on affected women, thus underlying the need for psychological support and medical treatment beyond fertile age. Perspective item This is a population-based cohort study showing decreased pain threshold and maximal pain tolerance in women with endometriosis up till late fertile age of 46 years. The pain was also found to be more bothersome and intense compared with controls.
J Ultrasound Med. 2018 Mar 2. doi: 10.1002/jum.14587. [Epub ahead of print]
Clinical Value of 3-Dimensional Ultrasound in Gynecology.
This report provides examples of using 3-dimensional ultrasound diagnostically in gynecology. The cost efficiency it provides and the wide range of applications it has support the routine use of this ultrasound technology in the practice of gynecology.
Chemosphere. 2018 Jun;200:388-396. doi: 10.1016/j.chemosphere.2018.02.120. Epub 2018 Feb 21.
The challenging use and interpretation of circulating biomarkers of exposure to persistent organic pollutants in environmental health: Comparison of lipid adjustment approaches in a case study related to endometriosis.
The gold-standard matrix for measuring the internal levels of persistent organic pollutants (POPs) is the adipose tissue, however in epidemiological studies the use of serum is preferred due to the low cost and higher accessibility. The interpretation of serum biomarkers is tightly related to the understanding of the underlying causal structure relating the POPs, serum lipids and the disease. Considering the extended benefits of using serum biomarkers we aimed to further examine if through statistical modelling we would be able to improve the use and interpretation of serum biomarkers in the study of endometriosis. Hence, we have conducted a systematic comparison of statistical approaches commonly used to lipid-adjust the circulating biomarkers of POPs based on existing methods, using data from a pilot case-control study focused on severe deep infiltrating endometriosis. The odds ratios (ORs) obtained from unconditional regression for those models with serum biomarkers were further compared to those obtained from adipose tissue. The results of this exploratory study did not support the use of blood biomarkers as proxy estimates of POPs in adipose tissue to implement in risk models for endometriosis with the available statistical approaches to correct for lipids. The current statistical approaches commonly used to lipid-adjust circulating POPs, do not fully represent the underlying biological complexity between POPs, lipids and disease (especially those directly or indirectly affecting or affected by lipid metabolism). Hence, further investigations are warranted to improve the use and interpretation of blood biomarkers under complex scenarios of lipid dynamics.
J Minim Invasive Gynecol. 2018 Mar 1. pii: S1553-4650(18)30145-6. doi: 10.1016/j.jmig.2018.02.015. [Epub ahead of print]
Laparoscopic Neuro-Navigation (LANN) for Deep Lateral Pelvic Endometriosis: Clinical and Surgical Implications.
Evaluation of clinical presentation and surgical outcome in patients with deep lateral pelvic endometriosis (dLPE).
Retrospective multicentric study (Canadian Task Force Classification II-2).
University tertiary referral centres.
148 women with deep infiltrating endometriosis (DIE).
Laparoscopic excision of DIE. Disease Distribution was classified as: Central Pelvic Endometriosis (CPE) when DIE involved one of these anatomic sites: cervix, vagina, uterosacral ligaments, rectum, bladder and pelvic peritoneum; superficial Lateral Pelvic Endometriosis (sLPE) when parametria, ureters or hypogastric plexus were involved; deep Lateral Pelvic Endometriosis (dLPE) in presence of sacral plexus and/or sciatic nerve infiltration.
MEASUREMENTS AND MAIN RESULTS:
All patients showed CPE. LPE was detected in 116 cases (78.4%); among these we observed dLPE in 41 patients (35.3%). dLPE occurred in 40% of women with CPE, and in 72.7% of patients with hypogastric plexus involvement. Thirty women with dLPE (73.2%) received gastrointestinal or urologic resection in addition to gynecological procedures compared with 40 patients (57.1%) without dLPE (p-value=0.001). No differences were observed in term of perioperative complications according to the presence of dLPE. At univariate/multivariate analysis chronic pelvic pain was the only predictor of dLPE (Odds ratio=3.041; p-value=0.003). Median preoperative VAS for dysmenorrhea (median 8, range 0-10) and dyspareunia (median 5, range 0-10) dropped to 0 after surgery. The median follow-up was 36 months (range 6-66) with a recurrence rate of 8.8%.
dLPE is not a rare event in women with DIE. Complete laparoscopic removal of endometriosis seems to ensure benefit in term of recurrence rate, without increased surgical morbidities.
Copyright © 2018. Published by Elsevier Inc.
Rev Pneumol Clin. 2018 Mar 1. pii: S0761-8417(18)30009-9. doi: 10.1016/j.pneumo.2018.01.005. [Epub ahead of print]
Thoracic endometriosis complicated with pneumopericard and iterative pneumothorax due to bullous dystrophy.[Article in French]
Thoracic endometriosis is a rare entity characterized by presence of endometrial tissue in pleura, lung parenchyma or airways. Most frequent manifestations are catamenial pneumothorax, hemothorax, hemoptysis and pulmonary nodules. We report here a rare case of a woman with thoracic endometriosis who developed iterative pneumothorax and pneumopericardium on bilateral bullous pulmonary dystrophy. She was a 37-year-old woman without any tobacco exposure and with previous history of pleural tuberculosis treated 5 years earlier. She was first referred to our centre for right pleuro-pneumothorax and hemorrhagic ascites. Pleural fluid examinations did not show any tuberculosis relapse, the evolution was favorable after thoracic drainage and there was no parenchymal lung abnormality on CT scan after surgery. Celioscopic peritoneal examination revealed stage IV peritoneal endometriosis. One year later, she was admitted for left catamenial pneumothorax. Thoracic CT scan showed apparition of large subpleural bulla. She underwent thoracotomy for bulla resection and left partial pleurectomy. Two years later, she was hospitalized for right pneumothorax and compressive pneumopericardium. Surgical lung biopsies confirmed pleuropulmonary endometriosis. Thoracotomy was performed for talcage pleurodesis and diaphragmatic leakages sutures. Lung bulla are rare in thoracic endometriosis, mechanism of their formation remains unknown. Pericardial involvement is rare in endometriosis; we report here a unique case of pneumopericardium.
Best Pract Res Clin Obstet Gynaecol. 2018 Feb 8. pii: S1521-6934(18)30029-4. doi: 10.1016/j.bpobgyn.2018.01.011. [Epub ahead of print]
Endometrial stem/progenitor cells and their role in the pathogenesis of endometriosis.
Human endometrium regenerates on a cyclical basis each month, likely mediated by endometrial stem/progenitor cells. Several types of stem/progenitor cells have been identified: CD140b+CD146+ or SUSD2+ endometrial mesenchymal stem cells (eMSCs), N-cadherin+ endometrial epithelial progenitor cells (eEPs), and side population (SP) cells, a heterogeneous population predominantly comprising endothelial cells. eMSCs reside in a perivascular niche and likely mediate angiogenesis and stromal regeneration. Human eEPs are located in the bases of glands in the basalis and are likely more primitive than SSEA-1+ basalis epithelial cells. Endometrial stem/progenitor cells may contribute to the pathogenesis of endometriosis by their retrograde shedding into the pelvic cavity, either after menarche or as a result of neonatal uterine bleeding. eMSCs may have a role in the generation of progesterone-resistant phenotype of endometrial stromal fibroblasts (eSFs) in endometriosis. In future clinical practice, endometrial stem/progenitor cells may be used to establish diagnosis of endometriosis or as therapeutic targets.
Gynecol Obstet Fertil Senol. 2018 Mar 1. pii: S2468-7189(18)30057-6. doi: 10.1016/j.gofs.2018.02.025.
Management of assisted reproductive technology (ART) in case of endometriosis related infertility: CNGOF-HAS Endometriosis Guidelines.
The management of endometriosis related infertility requires a global approach. In this context, the prescription of an anti-gonadotropic hormonal treatment does not increase the rate of non-ART (assisted reproductive technologies) pregnancies and it is not recommended. In case of endometriosis related infertility, the results of IVF management in terms of pregnancy and birth rates are not negatively affected by the existence of endometriosis. Controlled ovarian stimulation during IVF does not increase the risk of endometriosis associated symptoms worsening, nor accelerate the intrinsic progression of endometriosis and does not increase the rate of recurrence. However, in the context of IVF management for women with endometriosis, pre-treatment with GnRH agonist or with oestrogen/progestin contraception improve IVF outcomes. There is currently no evidence of a positive or negative effect of endometriosis surgery on IVF outcomes. Information on the possibilities of preserving fertility should be considered, especially before surgery.
Gynecol Obstet Fertil Senol. 2018 Mar 1. pii: S2468-7189(18)30046-1. doi: 10.1016/j.gofs.2018.02.014.
[Endometrioma and management by assisted reproductive technology: CNGOF-HAS Endometriosis Guidelines].
Could the presence of an endometrioma change the management of Assisted Reproductive Technology? The presence of an endometrioma (<6cm) at the time of stimulation or an endometrioma operated prior to stimulation have no impact on the quality of the embryos and the final results of IVF about the pregnancy and live birth rates despite a possible decrease in the number of oocytes retrieved and potentially higher doses of gonadotropins used. The discovery of an endometrioma during IVF stimulation should not lead to an interruption of the attempt. Their surgical treatment before IVF is not recommended just to improve fertility. It is discussed in case of painful symptomatology, depending on the size and/or in case of diagnosis doubt. The associated indications for ART management and surgical history for endometrioma should also be taken into account. There is no benefit of prophylactic surgery to decrease the risk of tubo-ovarian abscess post ovarian retrieval. It is not recommended to make a systematic trans-vaginal ultrasound guided aspiration with or without sclerotherapy of endometriomas before IVF in order to increase pregnancy rates, but it is reserved in case of endometrioma that may hinder the oocyte retrieval. Ethanol sclerotherapy decreases the recurrence rate of endometriomas without altering the results of IVF while a second surgery would have a deleterious effect.
Front Genet. 2018 Feb 16;9:42. doi: 10.3389/fgene.2018.00042. eCollection 2018.
Identification of Shared Molecular Signatures Indicate the Susceptibility of Endometriosisto Multiple Sclerosis.
Women with endometriosis (EMS) appear to be at a higher risk of developing other autoimmune diseases predominantly multiple sclerosis (MS). Though EMS and MS are evidently diverse in their phenotype, they are linked by a common autoimmune condition or immunodeficiency which could play a role in the expansion of endometriosis and possibly increase the risk of developing MS in women with EMS. However, the common molecular links connecting EMS with MS are still unclear. We conducted a meta-analysis of microarray experiments focused on EMS and MS with their respective controls. The GEO2R web application discovered a total of 711 and 1516 genes that are differentially expressed across the experimental conditions in EMS and MS, respectively with 129 shared DEGs between them. The functional enrichment analysis of DEGs predicts the shared gene expression signatures as well as the overlapping biological processes likely to infer the co-occurrence of EMS with MS. Network based meta-analysis unveiled six interaction networks/crosstalks through overlapping edges between commonly dysregulated pathways of EMS and MS. The PTPN1, ERBB3, and CDH1 were observed to be the highly ranked hub genes connected with disease-related genes of both EMS and MS. Androgen receptor (AR) and nuclear factor-kB p65 (RelA) were observed to be the most enriched transcription factor in the upstream of shared down-regulated and up-regulated genes, respectively. The two disease sample sets compared through crosstalk interactions between shared pathways revealed commonly up- and down-regulated expressions of 10 immunomodulatory proteins as probable linkers between EMS and MS. This study pinpoints the number of shared genes, pathways, protein kinases, and upstream regulators that may help in the development of biomarkers for diagnosis of MS and endometriosis at the same time through improved understanding of shared molecular signatures and crosstalk.
J Biol Regul Homeost Agents. 2018 Jan-Feb;32(1):21-28.
Relationship between methylation status of RASSF2A gene promoter and endometriosis-associated ovarian cancer.
Relationship between the methylation status of the RASSF2A gene promoter and endometriosis-associated ovarian cancer (EAOC) was explored. Between January 2013 and January 2016, tissue samples were collected from 30 patients diagnosed with ovarian endometriosis cyst (EC group), 30 patients diagnosed with ovarian endometrial adenocarcinoma (OEA group) and 30 patients diagnosed with ovarian clear cell carcinoma (OCC group). Additionally, 30 cases of normal endometrium tissues were collected for the control group. The methylation status of the RASSF2A promoter was evaluated by combined bisulfite restriction enzyme analysis (COBRA). RT-PCR was used to detect the expression level of RASSF2A mRNA in tissues. Relationship between methylation status and RASSF2A mRNA expression level and the patient age, tumor clinical stage, tumor grading and pathological type were analyzed. Results showed that in the OEA and OCC groups, the methylation degrees of the RASSF2A promoter were obviously higher than that of the other two groups. The expression level of RASSF2A mRNA in the OEA and OCC groups was lower than that of the other two groups. The methylation degree of the RASSF2A promoter was related to clinical staging and grading. No relationship between the methylation degree of the RASSF2A promoter and patients age and the pathological type of the tissue was detected. We concluded that the methylation status of the RASSF2A gene promoter could be considered an excellent indicator for early detection of ovarian cancers.
Best Pract Res Clin Obstet Gynaecol. 2018 Feb 8. pii: S1521-6934(18)30030-0. doi: 10.1016/j.bpobgyn.2018.01.012. [Epub ahead of print]
Genetics of endometriosis: State of the art on genetic risk factors for endometriosis.
Developments in high-throughput genotyping technology have driven discovery of genomic regions associated with an increased risk of endometriosis. In all, 16 genomic regions have been associated with risk of endometriosis in one or more populations. The latest meta-analysis including 17,045 endometriosis cases identified 14 genomic regions supported by results from multiple studies. No independent associations were identified from direct genotyping of common and low-frequency protein-coding variants. This suggests that the most common genetic factors that contribute to endometriosis risk are located in regulatory DNA sequences and alter the regulation of gene transcription. Evidence from different methods is essential to identify the target genes and transcripts that contribute to altered disease risk. Potential target genes in three chromosome regions showing altered gene regulation include LINC00339 and CDC42 on chromosome 1, CDKN2A-AS1 on chromosome 9, and VEZT on chromosome 12. Further functional studies are needed to confirm the causal genes in these and other regions to understand pathways that increase endometriosis risk and help identify novel targets for interventions to improve diagnosis and treatment.
Best Pract Res Clin Obstet Gynaecol. 2018 Feb 14. pii: S1521-6934(18)30031-2. doi: 10.1016/j.bpobgyn.2018.01.013. [Epub ahead of print]
Ultrasound diagnosis of endometriosis and adenomyosis: State of the art.
Transvaginal ultrasonography has become the primary test in the diagnosis of pelvic endometriosis and adenomyosis. A review of the literature on the diagnostic accuracy of ultrasonography in pelvic endometriosis and adenomyosis, as well as a comparison with magnetic resonance imaging, will be presented. Criteria for diagnosis of an endometrioma according to robust prospective data together with guidelines as to adequate reporting of the location of deep infiltrating endometriosis will be given. The sonographic features of adenomyosis including the differential diagnosis between focal adenomyosis and a uterine fibroid are reviewed. The available data in the literature on ultrasound diagnosis of pelvic endometriosis and adenomyosis, their clinical relevance, and their limitations are discussed.
Best Pract Res Clin Obstet Gynaecol. 2018 Feb 8.
Immunology of endometriosis.
The pathophysiology of endometriosis is not completely understood, but an aberrant immune response in the peritoneal environment seems to be crucial for the proliferation of ectopic endometrial cells – as those cells escape apoptosis and peritoneal cavity immunosurveillance. The growth of endometrial implants leads to the recruitment of a large number and diversity of immune cells and intense inflammation with increased pro-inflammatory cytokines, growth factors, and angiogenesis. There is substantial evidence of aberrant function of almost all types of immune cells in women with endometriosis: decreased T cell reactivity and NK cytotoxicity, polyclonal activation of B cells and increased antibody production, increased number and activation of peritoneal macrophages, and changes in inflammatory mediators. New clinical treatments for endometriosis are an urgent need, especially nonhormonal drugs. The study of immunology may clarify its role in the pathogenesis of endometriosis and contribute to the development of new therapeutic strategies.
J Gynecol Obstet Hum Reprod. 2018 Mar 3. pii: S2468-7847(18)30050-3. doi: 10.1016/j.jogoh.2018.02.003.
The definition of Endometriosis Expert Centres.
Golfier F, Chanavaz-Lacheray I, Descamps P, Agostini A, Poilblanc M, Rousset P, Bolze PA, Panel P, Collinet P, Hebert T, Graesslin O, Martigny H, Brun JL, Déchaud H, Malartic CM, Piechon L, Wattiez A, Chapron C, Daraï E.
Endometriosis is a common condition that causes pain and infertility. It can lead to absenteeism and also to multiple surgeries with a consequent risk of impaired fertility, and constitutes a major public health cost. Despite the existence of numerous national and international guidelines, the management of endometriosis remains suboptimal. To address this issue, the French College of Gynaecologists and Obstetricians (CNGOF) and the Society of Gynaecological and Pelvic Surgery (SCGP) convened a committee of experts tasked with defining the criteria for establishing a system of care networks, headed by Expert Centres, covering all of mainland France and its overseas territories. This document sets out the criteria for the designation of Expert Centres. It will serve as a guide for the authorities concerned, to ensure that the means are provided to adequately manage patients with endometriosis.
Gynecol Obstet Fertil Senol. 2018 Mar 3. pii: S2468-7189(18)30034-5. doi: 10.1016/j.gofs.2018.02.002. [Epub ahead of print]
Conventional analgesics and non-pharmacological multidisciplinary therapeutic treatment in endometriosis: CNGOF-HAS Endometriosis Guidelines.
A major symptom of endometriosis is pelvic pain with a wide range of intensity, rhythm, type, and expression, without clearly established relationship between pain and the disease. Endometriosis-associated pain has physical, psychological/behavioral and social consequences with a significant impact on patient quality-of-life in relation with the biopsychosocial model of chronic pain. Pain assessment in all of its dimensions, as well as assessing the consequences of pain is therefore a crucial part of therapeutic management. Conventional analgesics are commonly used although studies demonstrating their efficacy in the treatment of endometriosis-related pelvic pain are lacking. Non-steroid anti-inflammatory drugs (NSAIDs), known to be effective in dysmenorrhea unrelated to endometriosis, have not been recently re-assessed in patients with endometriosis. Following rigorous assessment, the characterization of neuropathic components of endometriosis-related pelvic pain may lead to treatment with antiepileptic of antidepressant drugs, although gabapentin and amitriptyline have yet to be specifically assessed in the setting of endometriosis-related pain. Other pharmacologically active compounds have been tested to treat endometriosis-related pain but did not demonstrate efficacy with sufficient level of evidence. Diets, dietary supplements and herbal medicine are often proposed and/or used as adjuncts without any conclusive evidence. Although the effects on endometriosis-related pain are methodologically difficult to assess, physical adjunctive therapies such as acupuncture, transcutaneous neurostimulation, osteopathy/chiropractics, physical therapy and physical activity, the long-term therapeutic relationship they establish may potentiate beneficial effects perceived by patients. However, it remains difficult to demonstrate significant effects of cognitive and/or behavioral interventions on endometriosis-related pain.
The complexity of managing endometriosis-related pain requires a holistic approach with sustained attention to the patient. Treatments, either pharmacologic or non-pharmacologic, including adjuvant therapies, associate a technical expertise to which a human approach must be added in order to bring value to these treatments. Multidisciplinary and/or inter disciplinary approaches are therefore essential to the care of patients suffering from endometriosis.
Copyright © 2018 Elsevier Masson SAS. All rights reserved.
Gynecol Obstet Fertil Senol. 2018 Mar 3. pii: S2468-7189(18)30045-X. doi: 10.1016/j.gofs.2018.02.013. [Epub ahead of print]
Surgical management of endometrioma: Different alternatives in term of pain, fertility and recurrence. CNGOF-HAS Endometriosis Guidelines.
Surgical management of ovarian endometrioma is most often part of a global approach of endometriosis pathology. Isolated endometrioma are rare. Laparoscopic cystectomy is the gold standard for surgical management of endometrioma. Nevertheless, this technique impacts the ovarian function. The hemostasis of the ovarian cyst bed should be performed to conserve the ovarian stroma. Ultrasonography-guided cyst aspiration, laparoscopic drainage and simple bipolar coagulation are not recommended as first line of treatment. Based on the actual literature, we cannot state the place of laser-vaporization and plasma-energy ablation in surgical management. Ethanol sclerotherapy could be an alternative to treat recurrent endometrioma. Uncompleted surgical removal of endometriosis lesions increases the recurrence rate. Endometriosis management should take into account the research and treatment of all the pelvic lesion, especially before surgical management of endometrioma. In this context, the evaluation of ovarian reserve could be useful before surgery.
Gynecol Obstet Fertil Senol. 2018 Mar 3. pii: S2468-7189(18)30036-9. doi: 10.1016/j.gofs.2018.02.004. [Epub ahead of print]
Minimal and mild endometriosis: Impact of the laparoscopic surgery on pelvic pain and fertility. CNGOF-HAS Endometriosis Guidelines.
Minimal and mild endometriosis (stage 1 and 2 AFSR) can lead to chronic pelvic pain and infertility but can also exist in asymptomatic patients. The prevalence of asymptomatic patients with minimal and mild endometriosis is not clear but typical endometriosis lesions are found in about 5 to 10% of asymptomatic women and more than 50% of painful and/or infertile women. Laparoscopic treatment of minimal and mild endometriotic lesions is justified in case of pelvic pain because their destruction decrease significatively the pain compared with diagnostic laparoscopy alone. In this context, ablation and excision give identical results in terms of pain reduction. Moreover, literature shows no interest in uterine nerve ablation in case of dysmenorrhea due to minimal and mild endometriosis. Then, it is recommended to treat these lesions during a laparoscopy realised as part of pelvic pain. On the other hand, it is not recommended to treat asymptomatic patients. With regard to treatment of minimal and mild endometriosis in infertile patients, only two studies can be selected and both show that laparoscopy with excision or ablation and ablation of adhesions is superior to diagnostic laparoscopy alone in terms of pregnancy rate. However, it is not recommended to treat these lesions when they are asymptomatic because there is no evidence that they can progress with symptomatic disease. There is no study assessing the interest to treat these lesions when they are found fortuitously. Adhesion barrier utilisation permits to reduce post-operative adhesions, however literature failed to demonstrate the clinical profit in terms of reduction of the risk of pain or infertility.
Gynecol Obstet Fertil Senol. 2018 Mar 3. pii: S2468-7189(18)30060-6. doi: 10.1016/j.gofs.2018.02.028. [Epub ahead of print]
Medical treatment for the management of painful endometriosis without infertility: CNGOF-HAS Endometriosis Guidelines.
To provide clinical practice guidelines for the management of painful endometriosis in women without infertility.
Systematic review of the literature literature since 2006, level of evidence rating, external proofreading and grading of the recommendation grade by an expert group according to HAS methodology.
Combined hormonal contraceptives (COP) and the levonorgestrel-releasing intra-uterin system (LNG-IUS) are recommended as first-line hormonal therapies for the treatment of painful endometriosis (grade B). Second-line therapy relies on oral desogestrel microprogestative, etonogestrel-releasing implant, GnRH analogs (GnRHa) and dienogest (grade C). It is recommended to use add-back therapy containing estrogen in association with GnRHa (grade B). After endometriosis surgery, hormonal treatment relying on COP or LNG-IUS is recommended to prevent pain recurrence (grade B). COP is recommended to reduce the risk of endometrioma recurrence after surgery (grade B) but the prescription of GnRHa is not recommended (grade C). Continuous COP is recommended in case of dysmenorrhea (grade B). GnRHa is not recommended as first line endometriosistreatment for adolescent girl because of the risk of bone demineralization (grade B). The management of endometriosis-induced chronic pain requires an interdisciplinary evaluation. Physical therapies improving the quality of life such as yoga, relaxation or osteopathy can be proposed (expert agreement). Promising medical alternatives are currently under preclinical and clinical evaluation.
Int J Med Sci. 2018 Feb 12;15(4):411-416. doi: 10.7150/ijms.23360. eCollection 2018.
Differences in C-type lectin receptors and their adaptor molecules in the peritoneal fluid of patients with endometriosis and gynecologic cancers.
Endometriosis, although not malignant, has clinically demonstrated properties of invasiveness and metastasis. The pathogenesis of endometriosis, however, has not yet been elucidated. The immunological differences between endometriosis and malignant gynecologic tumors were analyzed by assessing C-type lectin receptors, which are associated with innate immunity, and immunoglobulin secretion, which is associated with B cell adaptive immunity, in the peritoneal fluid of these patients. Peritoneal fluid samples were obtained from 42 patients with benign masses (control group), 38 with endometriosis, and 43 with gynecologic (ovarian, uterine, and cervical) cancers. The levels of expression in these samples of mRNAs encoding the C-type lectin receptors Dectin-1, MR1, MR2, DC-SIGN, Syk, Card 9, Bcl 10, Malt 1, src, Dec 205, Galectin, Tim 3, Trem 1, and DAP 12, were measured by real-time reverse transcription polymerase chain reaction, and the concentrations of IgG, IgA and IgM were measured by enzyme-linked immunosorbent assays (ELISA). Findings in the three groups were compared. The level of galectin mRNA was significantly lower, and the levels of MR2 and DAP 12 mRNAs significantly higher, in the endometriosis than in the control group (p<0.05 each). Compared with the gynecologic cancer group, the level of Bcl 10 mRNA was significantly lower, and the levels of MR1, MR2, Syk, Card 9, Malt 1, Dec 205, Tim 3, and DAP 12 mRNAs significantly higher, in the endometriosis group (p<0.05 each). The levels of MR2 and DAP 12 mRNAs were significantly higher in the endometriosis than in the control group (p<0.05 each), whereas the level of galectin mRNA was similar in the endometriosis and gynecologic cancer groups. IgA and IgG concentrations in peritoneal fluid were significantly lower in the gynecologic cancer than in the control group (p<0.05 each). However, concentrations of all three immunoglobulins in the endometriosis group did not differ from those in the other two groups (p>0.05). C-type lectin receptors and immunoglobulins act cooperatively and are closely associated in the pathogenesis of endometriosis. The decreased expression of galectin mRNA in the peritoneal fluid of the endometriosis group suggests that endometriosis and gynecologic cancers have similar immunologic characteristics.
J Surg Case Rep. 2018 Feb 28;2018(2):rjy028. doi: 10.1093/jscr/rjy028. eCollection 2018 Feb.
False-positive radioiodine accumulation in a huge pelvic mass after thyroidectomy for papillary carcinoma, a case report from Syria.
Iodine has always been connected to thyroid gland, and the fact that thyroid tissue traps, organificates and stores iodine more than other tissues is well known, hence the use of radioiodine as a diagnostic and therapeutic tool for thyroid disorders. However, false-positive cases do occur. We present a case of a 34-year-old patient who underwent total thyroidectomy for papillary carcinoma. Results of follow up TSH, thyroglobulin and thyroglobulin antibody tests after surgery lead to two rounds of radioactive iodine. After that, a radioiodine whole-body scan showed high uptake in the pelvis above bladder. Computed tomography scan showed a pelvic heterogeneous mass with some calcifications. Surgical removal and subsequent pathology confirmed the absence of metastasis. The final pathological diagnosis was serous cystadenoma, endometriosis cyst and leiomyoma. As the real cause behind false-positive iodine uptake by these tissues has yet to be determined, careful assessment should be considered in any suspicious case.
J Surg Case Rep. 2018 Feb 28;2018(2):rjy034. doi: 10.1093/jscr/rjy034. eCollection 2018 Feb.
Bowel endometriosis treated with simultaneous ileocecal and rectal resection.
A 43-year-old female noticed hematochezia and lower-right abdominal pain during menstruation. Her family doctor detected a mass by computed tomography at the ileocecum. She was referred to our hospital and colonoscopy was performed. We observed extrinsic pressure resulting in mucosal change at the ileocecum. We also observed a submucosal tumor-like lesion at the rectosigmoid. We performed biopsy from both lesions, both were benign. Ileocecal resection and rectal low anterior resection were performed for diagnosis. Redness, induration and serosal dimpling were recognized at the ileocecum, rectosigmoid and upper rectum. All lesions had endometorial tissue in muscular layer, so pathological diagnosis was bowel endometriosis. Bowel endometriosis occurring in multiple parts and where two colectomies were performed simultaneously is very rare. To determine the optimal method of treatment for the bowel endometriosis, detailed preoperative examination must be performed, specifically complete surgical resection of the lesion for definite diagnosis.
J Psychosom Obstet Gynaecol. 2018 Mar 8:1-4. doi: 10.1080/0167482X.2018.1445221. [Epub ahead of print]
Are symptoms after a colorectal segmental resection in deep endometriosis really improved? The point of view of women before and after surgery.
Bowel endometriosis can cause debilitating symptoms. Surgical colorectal resection is often required for symptomatic relief. Aim of our study was to evaluate quality of life over a one-year follow-up period in patients submitted to a colorectal resection for the treatment of deep endometriosis. Change in intestinal and extra-intestinal symptoms, and reproductive outcome were also evaluated.
A prospective observational study was conducted on a cohort of 20 women affected by intestinal endometriosis and submitted to a laparoscopic colorectal resection. The subjects completed a questionnaire about quality of life (SF-36), and they scored in a 100-point rank questionnaire gynecological, urinary and gastrointestinal symptoms, pre-operatively and one- year postoperatively.
Significant improvements were observed in all domains of the SF-36 throughout the study period. Dysmenorrhea, dyspareunia and not menstrual pelvic pain showed a significant decrease 1 year after surgery. There was also a decrease in abdominal pain, rectal bleeding and constipation but not of nausea, abdominal pain, defecation pain, tenesmus, diarrhea, mucorrhea. Also some urinary symptoms did not improve.
The radical surgical approach has a positive impact on quality of life, although it does not improve all the symptoms complained before surgery. Clear pre-surgical counseling and careful patient selection is suggested.
Expert Rev Mol Med. 2018 Mar 8;20:e2. doi: 10.1017/erm.2017.13.
Oestrogen, progesterone and stem cells: the discordant trio in endometriosis?
Oestrogen-progesterone signalling is highly versatile and critical for the maintenance of healthy endometrium in humans. The genomic and nongenomic signalling cascades initiated by these hormones in differentiated cells of endometrium have been the primary focus of research since 1920s. However, last decade of research has shown a significant role of stem cells in the maintenance of a healthy endometrium and the modulatory effects of hormones on these cells. Endometriosis, the growth of endometrium outside the uterus, is very common in infertile patients and the elusiveness in understanding of disease pathology causes hindrance in selection of treatment approaches to enhance fertility. In endometriosis, the stem cells are dysfunctional as it can confer progesterone resistance to their progenies resulting in disharmony of hormonal orchestration of endometrial homeostasis. The bidirectional communication between stem cell signalling pathways and oestrogen-progesterone signalling is found to be disrupted in endometriosis though it is not clear which precedes the other. In this paper, we review the intricate connection between hormones, stem cells and the cross-talks in their signalling cascades in normal endometrium and discuss how this is deregulated in endometriosis. Re-examination of the oestrogen-progesterone dependency of endometrium with a focus on stem cells is imperative to delineate infertility associated with endometriosis and thereby aid in designing better treatment modalities.
Gynecol Obstet Fertil Senol. 2018 Mar 4. pii: S2468-7189(18)30040-0. doi: 10.1016/j.gofs.2018.02.008. [Epub ahead of print]
Diagnostic strategies for endometriosis: CNGOF-HAS Endometriosis Guidelines.
In this chapter we have examined the possibilities of screening endometriosis, both in the general population as well as in the target population. We then proposed decision trees, for primary and secondary care. Currently, there is not enough data in the literature to develop or organize a screening test for endometriosis. Screening for endometriosis is not recommended in the general population (level A). There is also no evidence to support systematic screening in a population with genetic risk factors (endometriosis in a relative), or with other clinical risk factors (increased menstrual volume, short cycles, early menarche) (level A). However, it is possible to propose a decision tree for the management of chronic pelvic pain symptoms (dysmenorrhea, dyspareunia, non-menstrual pelvic pain). The search for symptoms suggestive of endometriosis (intense dysmenorrhea [visual analogue scale >7/10, frequent abstention, resistance to level 1 analgesics], infertility) should be systematic. The search for localizing symptoms of deep endometriosis (deep dyspareunia, cyclic defecation pain, cyclic urinary signs) enables to orient the patient to second line evaluation. We propose a decision tree for second and third line evaluations, according to the suspicion and/or the discovery of deep lesions with specific locations, or the suspicion of superficial lesions.
J Zoo Wildl Med. 2018 Mar;49(1):210-213. doi: 10.1638/2017-0109R.1.
SURGICAL MANAGEMENT OF UTERINE LESIONS IN TWO CAPTIVE ORANGUTANS ( PONGO SPP.).
Uterine lesions in two orangutans were effectively managed with surgical intervention. A 26-year-old hybrid orangutan ( Pongo spp.) was diagnosed with uterine adenomyosis based on advanced imaging. Histologic evaluation identified multifocal myometrial endometriosis, a variant of adenomyosis. A 27-year-old Bornean orangutan ( Pongo pygmaeus) was diagnosed with a focal uterine fibroid based on histologic examination. The animals were housed at separate institutions and initially presented with dysmenorrhea and menorrhagia. Both animals were treated intermittently for episodes of dysmenorrhea, with recurrence of clinical signs after each treatment. Due to the lack of consistent response to medical management, an ovariohysterectomy in the hybrid orangutan and a myomectomy in the Bornean orangutan were performed and resulted in complete resolution of clinical signs. Surgical management of adenomyosis and neoplasia has previously been reported in nonhuman primates. These cases are the first known documentation of surgical management of multifocal myometrial endometriosis and a fibroid in orangutans.
J Zoo Wildl Med. 2018 Mar;49(1):79-85. doi: 10.1638/2016-0171R1.1.
LESIONS OF THE FEMALE REPRODUCTIVE TRACT IN JAPANESE MACAQUE ( MACACA FUSCATA) FROM TWO CAPTIVE COLONIES.
Reproductive lesions have been described in various nonhuman primate species, including rhesus macaques ( Macaca mulatta), cynomolgus macaques ( Macaca fascicularis), baboons ( Papio spp.), squirrel monkeys ( Saimiri sciureus), and chimpanzees ( Pan spp.); however, there are few publications describing reproductive disease and pathology in Japanese macaques ( Macaca fuscata). A retrospective evaluation of postmortem reports for two captive M. fuscata populations housed within zoos from 1982 through 2015 was completed, comparing reproductive diseases diagnosed by gross pathology and histopathology. Disease prevalence, organs affected, and median age at death between the two institutions was also compared. Fifteen female captive M. fuscata, ranging in age from 15 to 29 yr were identified with reproductive tract lesions, including endometriosis, endometritis, leiomyoma, leiomyosarcoma, and adenomyosis. No significant differences were identified in disease prevalence, organs affected, and median age of death between the two institutions. Endometriosis was the most common disease process identified and was found in 10 of the 15 cases (66.7%), followed by leiomyoma (4 of 15; 26.7%). In four cases (26.7%), severe endometriosis and secondary hemorrhage was indicated as the cause of death or the primary reason for humane euthanasia. These findings were compared with a separate population of Japanese macaques managed within a research facility in the United States, with a prevalence of endometriosis of 7.6%. This study discusses possible risk factors and potential treatment options for the management of endometriosis in captive M. fuscata.
Biol Reprod. 2018 Mar 6. doi: 10.1093/biolre/ioy057. [Epub ahead of print]
Evaluation of PAI-1 in endometriosis using a homologous immunocompetent mouse model.
To analyze the role of PAI-1 (plasminogen activator inhibitor 1) in endometriotic lesion growth, we studied the effect of PAI-1 inhibition by PAI-039 using a homologous mouse model of endometriosis that allows non-invasive monitoring. Endometrial tissue from donor mice was collected, labeled with mCherry adenovirus, and implanted into a subcutaneous pocket on the ventral abdomen of recipient mice. Seven days after transplantation, mice were randomly allocated in two groups and treated once daily for two weeks with either vehicle (control group) or PAI-1 inhibitor (PAI-039 group). Endometriotic lesion size generated in recipient mice was monitored by mCherry signal. Animals were euthanized 21 days after endometrial tissue implantation and endometriotic lesions were harvested for fibrin deposit and vascularization analyses. Collagen content was also examined to determine the overall effects of proteolysis on extracellular matrix degradation. We demonstrated that endometriotic lesions generated in recipient mice from both groups presented characteristics typical of human endometriotic lesions. We observed a significant decrease in fluorescence signal in endometriotic lesions from the PAI-039 group at the beginning of the treatment correlated with a decrease in endometriotic lesion size. PAI-1 inhibition significantly decreased lesion cell proliferation. In addition, endometriotic lesions from the PAI-1 inhibition group showed a decreased percentage of neovascularization as well as fibrin deposits. However, the density and distribution of collagen were not affected by PAI-039. Our results suggest that in vivo inhibition of PAI-1 by PAI-039 may be a useful strategy to reduce endometriotic lesion size by blocking angiogenesis.
Gynecol Obstet Fertil Senol. 2018 Mar 5. pii: S2468-7189(18)30061-8. doi: 10.1016/j.gofs.2018.02.029. [Epub ahead of print]
Management of painful endometriosis in adolescents: CNGOF-HAS EndometriosisGuidelines.
To analyse the literature on the treatment of adolescent painful endometriosis.
This work is based on a Review of the literature between January 2006 and December 2017. The Medline (Pubmed) and Cochrane database were searched for meta-analyzes, randomized trials, literature reviews, controlled, not controlled and retrospective studies published on the subject. Studies concerning adolescent’s dysmenorrhea without endometriosis were excluded.
Study quality is heterogeneous. Dienogest and GnRH agonists (GnRHa) are the only treatments specifically evaluated for the treatment of adolescent endometriosis. They reduce the pain associated with endometriosis. Combined oral contraceptives have not been studied in the context of endometriosis but they are effective on dysmenorrhea. Add back therapy, containing estrogens improves bone mineral density and quality of life for young women treated with GnRHa.
Medical treatment of endometriosis in adolescent is associated with risks related to the young age. The therapeutic strategy should take into account the adverse effects of each treatment.
Copyright © 2018 Elsevier Masson SAS. All rights reserved.
PLoS One. 2018 Mar 9;13(3):e0194011. doi: 10.1371/journal.pone.0194011. eCollection 2018.
Women with adenomyosis are at higher risks of endometrial and thyroid cancers: A population-based historical cohort study.
Both adenomyosis and endometriosis are characterized by the presence of ectopic endometrial glands and stroma and have been suggested to share some characteristics with malignant tumors. Although accumulating evidence indicates that endometriosis is associated with some cancer types, the cancer risks in patients with adenomyosis have been rarely examined. In this study, we investigated the relationship between adenomyosis and risks of common cancers.
This study included a cohort of 12,447 women with adenomyosis but not endometriosis, born in 1951-1984, and a cohort of 124,470 adenomyosis-free women matched by birth year. Their medical records (collected between 1996 and 2011) were obtained from the National Health Insurance Research Database of Taiwan. We first compared the distribution of cancer-free survival (CFS) between cohorts with and without adenomyosis. Subsequently, within the adenomyosis cohort, we examined whether time-to-onset of the identified cancer type was correlated with time-to-onset of adenomyosis. The Cox proportional hazards model was used to compare the distribution of CFS between the adenomyosis and adenomyosis-free cohorts and between the early- and late-diagnosed adenomyosis groups. For comparison, we further evaluated the cancer risks for a cohort of 10,962 women with endometriosis but not adenomyosis and a birth-year matched cohort of 109,620 endometriosis-free women.
Compared with adenomyosis-free women, patients with adenomyosis had higher risks of endometrial and thyroid cancers, with estimated hazard ratios (HRs) (95% confidence interval) of 2.19 (1.51-3.16) and 1.70 (1.29-2.24), respectively. For both cancers, distributions of CFS were not significantly different between the early- and late-diagnosed adenomyosis groups. Furthermore, compared with endometriosis-free women, patients with endometriosis had higher risks of endometrial and ovarian cancers, with HRs of 1.89 (1.07-3.35) and 2.01 (1.27-3.16), respectively.
Women with adenomyosis are at higher risks of endometrial and thyroid cancers, while women with endometriosis are at higher risks of endometrial and ovarian cancers.
Best Pract Res Clin Obstet Gynaecol. 2018 Feb 15. pii: S1521-6934(18)30037-3. doi: 10.1016/j.bpobgyn.2018.01.019. [Epub ahead of print]
Endometriosis, endometrioma, and ART results: Current understanding and recommended practices.
Endometriosis and infertility are linked in a complex relationship, and a number of different pathogenetic mechanisms may associate the two. Endometriosis is diagnosed in 6-8% of women undergoing ART. Women with endometriosis appear to have similar ART outcomes compared to controls in terms of live birth rates, despite a lower oocyte quality. Laparoscopy should not be routinely performed before ART with the only aim to diagnose mild or moderate endometriosis, but if the latter is found, surgical removal can be considered, as it might improve pregnancy rates. In case of more severe forms of the disease (endometrioma and deep infiltrating endometriosis), the benefits of surgery before ART are uncertain and must be balanced against risks. Management decisions should be individualized based on patient choice, age, associated symptoms, and the risk of repeat surgery.
Gynecol Obstet Fertil Senol. 2018 Mar 6. pii: S2468-7189(18)30047-3. doi: 10.1016/j.gofs.2018.02.015.
Management by assisted reproductive technology in women with endometriosis: CNGOF-HAS Endometriosis Guidelines.
Should the presence of endometriosis change the management of assisted reproductive technology? There is no difference in pregnancy rate after IVF between an agonist or antagonist protocol in patients with endometriosis, so the choice between one or the other of these protocols is free. But the review of the literature has shown an improvement in the chances of pregnancy in case of prolonged ovulation suppression before stimulation for IVF with a GnRH agonist analogue or with oral contraception, especially in cases of severe endometriosis. Endometriosis, regardless of the stage and type of lesions, would have no effect on the IVF results in terms of pregnancy rate and live birth rate, but with a lower number of oocytes collected, especially in cases of severe endometriosis. In a context of superficial endometriosis without pain and of infertility, surgical treatment of superficial endometriosis is not recommended just to increase the chances of pregnancy in IVF. Surgery may have a place in case of failure of IVF to improve the results of the ART. In case of recurrence of endometriosis, surgery is not better than IVF, a medico-surgical concertation is recommended. In addition, studies on ovulation stimulation for IVF do not show any aggravation of the symptoms associated with endometriosis lesions, or an acceleration of its progression, or an increase in the rate of recurrence of the disease.
Contemp Clin Trials. 2018 Mar 7;68:1-6. doi: 10.1016/j.cct.2018.03.002
Evaluation, validation and refinement of noninvasive diagnostic biomarkers for endometriosis (ENDOmarker): A protocol to phenotype bio-specimens for discovery and validation.
Endometriosis is a chronic, estrogen dependent condition that affects 5-10% of reproductive aged women and is associated with pelvic pain and infertility. As the approach to therapy shifts from surgical ablation to pharmacological control, a non-surgical mode of diagnosis would be desirable. The ENDOmarker study was designed by the NICHD Reproductive Medicine Network (RMN) to obtain well characterized and phenotyped bio specimens in a standardized fashion from women with and without endometriosis.
Development of a diagnostic test.
Academic medical centers.
This study will enroll up to 500 participants, and follow them for up to 5 months. Included subjects are aged 18-44, scheduled to undergo gynecologic surgery (laparoscopy/laparotomy) for clinical reasons.
Presence and stage of endometriosis (or its absence) is characterized by visual examination at the time of surgery. Subjects will undergo extensive clinical evaluation pre-operatively and at visits one and four months postoperatively. Endometrial biopsy, blood, urine and disease specific questionnaires will be collected at each visit.
Samples will be placed in a bio-repository to be used to validate and optimize the clinical use of genomic classifiers of the endometrium alone or in combination with serum cytokines as a non-surgical composite marker of endometriosis.
This protocol can serve as a reference for objective collection of high quality bio specimens for discovery or validation of potential nonsurgical diagnosis of presence or severity of disease.