2009 Nov 5. [Epub ahead of print]

Intra-abdominal hemorrhage due to previously unknown endometriosis in the third trimester of pregnancy with uneventful neonatal outcome: A case report.

Grunewald C, Jördens A.

Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.

Am J Reprod Immunol. 2009 Dec;62(6):352-6.

Increased expression of glutathione by estradiol, tumor necrosis factor-alpha, and interleukin 1-beta in endometrial stromal cells.

Lee SR, Kim SH, Lee HW, Kim YH, Chae HD, Kim CH, Kang BM.

Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Korea.

PROBLEM: The intracellular antioxidant system, based on glutathione (GSH), plays a key role in endometrial detoxification reactions and has been proposed to be involved in the pathogenesis endometriosis. This study was designed to evaluate whether estradiol (E(2)) and proinflammatory cytokines have any effects on expression of glutathione in endometrial stromal cells (ESCs). METHOD OF STUDY: Glutathione levels were measured utilizing high-performance liquid chromatography following in vitro culture and treatment of ESCs with estradiol, tumor necrosis factor-alpha (TNF-alpha) and interleukin 1-beta (IL-1beta). RESULTS: The GSH level in E(2) (10(-8) m) treatment group was significantly higher than in the control group at 48 h (P < 0.05). In vitro treatment of ESCs with TNF-alpha 10 ng/mL as well as E(2) (10(-8) m) plus TNF-alpha 10 ng/mL for 48 hr also led to a significant increase in GSH level (P < 0.05; P < 0.05, respectively). Both IL-1beta 10 ng/mL and E(2) (10(-8) m) plus IL-1beta 10 ng/mL for 48 hr increased GSH level significantly (P < 0.05; P < 0.05, respectively) as well. CONCLUSIONS: These findings might suggest that increased production of estradiol and proinflammatory cytokines in the peritoneal cavity possibly leads to the establishment of endometriosis through increased level of GSH.

Kyobu Geka. 2009 Nov;62(12):1093-6.

Repeated catamenial pneumothorax with pleural and diaphragmatic endometriosis; report of a case.

[Article in Japanese]

Tamaki M, Yoshizawa K, Okumura K, Miura K.

Department of Chest Surgery, Takamatsu Red-cross Hospital, Takamatsu, Japan.

A 31-year-old female with 2 episodes of right pneumothorax related to onset of menstruation was reported. Thoracoscopy revealed the presence of some cystic lesions in the diaphragm. Partial resection of the diaphragm including the lesions was performed. Histologial findings of the resected diaphragm showed stromal endometriosis. One month after operation, she had a recurrent right pneumothorax related to onset of menstruation. A pinhole perforation of the lower lobe was noted at 2nd surgery. Microscopic examination of the resected lung disclosed endometrial stroma in the macroscopically normal lung tissue. Since air leakage from chest tube continued after surgery, the hormonal therapy with a gonadotropin-releasing hormone analogue was started, and she was discharged from the hospital 3 weeks after hormonal therapy. Report of the demonstration of endmetriosis in the visceral pleura and diaphragm is very rare and the present case is very suggestive is considering the mechanism of the development of this disease.

Arch Esp Urol. 2009 Oct;62(8):653-656.

Obstructive uropathy secondary to vesico-ureteral endometriosis: clinical, radiologic and pathologic features.

[Article in English, Spanish]

Calvo Pulido J.

Radiology, Urology and Pathologic Anatomy. Hospital Clínico of Málaga. Spain.

OBJECTIVES: To report the case of a 37 year-old woman suffering from endometriosis of the urinary tract, that presented with lumbar and pelvic pain associated to cyclic recurrent haematuria. METHODS: Following history, physical examination, abdomino-pelvic ultrasound (USS), CT scan and cystoscopy with biopsies, surgical treatment was indicated RESULTS: Imaging (USS-CT ) revealed a protrusion of the left bladder hemitrigone with a nodular, irregular thickening and ipsilateral grade II-III/IV uretero-hydronefrosis. Cistoscopy confirmed a swollen and oedematous lesion in left hemitrigone that seemed extrinsic in origin. With the clinical diagnosis of a possible neoplasia of gynaecological origin, the patient underwent surgical treatment consisting in radical hysterectomy with bilateral oophorectomy, partial cystectomy and left ureteroneocystostomy. CONCLUSIONS: The frequency of endometriosis in the urinary tract is relatively low and therefore, endometriosis presenting with ureteral obstruction (uretero-hydronephrosis) has been rarely reported in the literature and should be part of the differential diagnosis in young women, especially if symptoms are cyclic. The treatment is surgery and the final diagnosis by pathology report.

Mol Hum Reprod. 2009 Nov 5. [Epub ahead of print]

Genetic Association of Phase I and Phase II Detoxification Genes with Recurrent Miscarriages among North Indian Women.

Parveen F, Faridi RM, Das V, Tripathi G, Agrawal S.

Department of Medical Genetics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow (UP) India.

Allelic variants of the detoxification genes that have impaired biotransformation functions may increase susceptibility to reproductive toxicity leading to endometriosis, recurrent miscarriage (RM) or poor pregnancy outcome. In the present study, we have investigated CYP1A1, CYP2D6, GSTT1, GSTP1 and GSTM1, which are involved in the phase I and phase II detoxification systems, in relation to their role in the etiology of unexplained recurrent miscarriages (RM). In a case control study, we have investigated 200 females with RM and 300 age and ethnically matched healthy controls with successful reproductive history from North India. The frequencies of phase I wild-type genotypes of CYP1A1 and CYP2D6 in RM cases were 0.56 and 0.60, whereas in controls these were 0.68 and 0.65 respectively (both p<0.05). The GSTM1 null-genotype frequencies were 0.66 and 0.84 among RM cases and controls respectively, the GSTT1 null- genotype frequencies were 0.52 and 0.45 (p<0.005) and the GSTP1 variant allele frequencies were 0.23 and 0.20 respectively. In conclusion, we observed significant protective effects of phase I wild-type genotypes and association of the GSTT1 null genotype with RM. Through combined analyses we have highlighted the importance of the balance of phase I/phase II detoxification systems, in the etiology of recurrent miscarriage.

Hum Reprod. 2009 Nov 5. [Epub ahead of print]

Role of TGF-{beta}s in normal human endometrium and endometriosis.

Omwandho CO, Konrad L, Halis G, Oehmke F, Tinneberg HR.

Department of Biochemistry, University of Nairobi, Nairobi, Kenya.

Endometriosis is characterized by presence of endometrial tissue outside the uterus. Prevalence is estimated at 6-10% in the general female population and many patients experience pain and/or infertility. Diagnosis is achieved by laparoscopic intervention followed by histological confirmation of viable endometriotic tissue. Mild cases are managed medically with contraceptive steroids and non-steroidal anti-inflammatory agents. Surgery provides relief to women in pain but symptoms recur in 75% of cases within 2 years. Starting with menstruation, we have categorized endometriosis into six stages, namely (1) shedding of cells, (2) cell survival, (3) escape from immune surveillance, (4) adhesion to peritoneum, (5) angiogenesis and (6) bleeding. In most of these biological processes, which resemble metastasis, transforming growth factor-beta (TGF-betas) and their high-affinity receptors are involved directly or indirectly. TGF-betas are abundantly and differentially expressed in the endometrium under hormonal control. Although they are preferentially synthesized in the stroma, glands and macrophages also secrete TGF-betas into the uterine fluid, where interaction with preimplantation embryos is suspected. Because mRNA and protein expression of all three TGF-betas is increased around menstruation, we suggest that TGF-betas might be involved in initiation of menstruation. Furthermore, because of high postmenstrual TGF-beta3 levels, we suppose that it might participate in scarless postmenstrual regeneration of endometrium. Our suggestions pave the way to novel routes of investigation into the roles of TGF-betas during menstruation and endometriosis.

J Minim Invasive Gynecol. 2009 Nov 3. [Epub ahead of print]

Peritoneal Vascular Density Assessment Using Narrow-Band Imaging and Vascular Analysis Software, and Cytokine Analysis in Women With and Without Endometriosis.

Kuroda K, Kitade M, Kikuchi I, Kumakiri J, Matsuoka S, Kuroda M, Takeda S.

Department of Obstetrics and Gynecology, Juntendo University School of Medicine, Tokyo, Japan (all authors).

The development and onset of endometriosis is associated with angiogenesis and angiogenic factors including cytokines. We analyzed intrapelvic conditions in women with endometriosis via vascular density assessment of grossly normal peritoneum and determination of cytokine levels in peritoneal fluid. Seventy-three patients underwent laparoscopic surgery because of gynecologic disease including endometriosis in our department using a narrow-band imaging system. Each patient was analyzed for peritoneal vascular density using commercially available vascular analysis software (SolemioENDO ProStudy; Olympus Corp, Tokyo, Japan). Each patient was also subjected to analysis of interleukin 6 (IL-6), IL-8, tumor necrosis factor-alpha, and vascular endothelial growth factor concentrations in peritoneal fluid. We defined 4 groups as follows: group 1, endometriosis: gonadotropin-releasing hormone (GnRH) agonist administration group (n=27); group 2, endometriosis: GnRH agonist nonadministration group (n=15); group 3, no endometriosis: GnRH agonist administration group (n=18); and group 4, no endometriosis: GnRH agonist nonadministration group (n=13). No significant differences in peritoneal vascular density between the 4 groups were found under conventional light; however, under narrow-band light, vascular density in the endometriosis groups (groups 1 and 2) was significantly higher. Cytokine analysis of the 4 groups determined that IL-6 and IL-8 concentrations were significantly higher compared with the no endometriosis groups (groups 3 and 4). Tumor necrosis factor-alpha and vascular endothelial growth factor concentrations were not significantly different between groups. In endometriosis, peritoneal vascular density was significantly higher as assessed using the narrow-band imaging system and SolemioENDO ProStudy, whereas GnRH agonist did not obviously decrease vascular density but IL-6 concentration was lower in the GnRH agonist administration group.

Nephron Clin Pract. 2009 Nov 3;114(2):c89-c94. [Epub ahead of print]

Ureteral Endometriosis: A Rare and Underdiagnosed Cause of Kidney Dysfunction.

Ponticelli C, Graziani G, Montanari E.

Division of Nephrology IRCCS Humanitas, Ospedale San Paolo, Milan, Italy.

Little attention has been paid by the renal literature to ureteral endometriosis, a rare and silent disorder that can eventually lead to renal failure. In endometriosis, the ureteral involvement can be limited to a single ureter, more often the left one, or both ureters with consequent urine tract obstruction and ureterohydronephrosis. In most cases, the ureteral obstruction is caused by endometrial tissue surrounding the ureter (extrinsic ureteral endometriosis). In the remaining cases, endometrial cells are located within the ureter (intrinsic ureteral endometriosis). Progressive ureteral obstruction can be insidious in onset and can ultimately lead to renal failure if a correct diagnosis is missed. The true incidence of renal failure caused by endometriosis is completely unknown, although cases have been reported in the literature. The diagnosis of ureteral endometriosis is difficult since the disease may be clinically silent or associated with non-specific symptoms. Only a high index of suspicion and radiological support may help to obtain an early diagnosis. However, while renal imaging is useful in the cases of extrinsic endometriosis, the diagnosis of intrinsic endometriosis often requires ureteroscopy or laparoscopy. The prognosis of ureteral endometriosis depends on the time of diagnosis. In too many cases of bilateral obstruction, the patient is referred to the nephrologist because of an advanced, irreversible renal failure. Although some patients may benefit from progestin or anti-arotamase therapy, in most cases of ureteral endometriosis surgery is needed, laparoscopy surgery being preferred today to laparatomy. Copyright © 2009 S. Karger AG, Basel.

Int J Epidemiol. 2009 Nov 3. [Epub ahead of print]

On the roles of skin type and sun exposure in the risk of endometriosis and melanoma.

Grant WB.

Pathologica. 2009 Apr;101(2):93-6.

Endometrial stromal sarcoma presenting as a cystic abdominal mass.

Doghri R, Mrad K, Driss M, Sassi S, Abbes I, Dhouib R, Hechiche M, Romdhane KB.

Pathology Department of Salah Azaiez Institute, Bab Saadoun, Tunis, Tunisia. karima.mrad@rns.tn

Endometrial stromal sarcoma (ESS) is rarely localized in extrauterine sites if metastasis or local extension of the primary uterine tumour are excluded, and diagnosis can be delayed because of the unusual site. We report a case of abdominal ESS in a 45-year-old woman who presented with an abdominal complaint. Ultrasound of the abdomen showed a large multiloculated cystic mass. The complete excision of the tumour revealed ESS arising in endometriosis. The tumour expressed hormonal receptors and the patient was administered hormonal therapy. ESS has a better prognosis than the sarcoma that is part of differential diagnosis, and is associated with endometriosis in about one-half of cases.

Pathologica. 2009 Jun;101(3):130-2.

Unusual cause of intestinal obstruction: ileal endometriosis.

Chaâbouni S, Makni SK, Kallel RI, Gouiaa N, Bahri I, Mnif L, Affes N, Boudawara T.

Department of Pathology, Habib Bourguiba University Hospital, Sfax, Tunisia.

Endometriosis is a common condition affecting the female genital tract, but involvement of the ileum is very rare. Its symptoms are vague and are similar to other benign and malignant disorders, and radiographic findings lack specificity. We report the case of a 23-year-old woman presenting with acute intestinal obstruction for whom preoperative diagnosis favoured acute appendicitis. Laparotomy revealed ileal stenosis. A partial small bowel resection was performed. Pathological examination diagnosed ileal endometriosis. Endometriosis may be a cause acute abdominal pain in women, and should be considered in differential diagnosis. Difficulties in establishing its diagnosis are discussed.

Yonsei Med J. 2009 Oct 31;50(5):732-5. Epub 2009 Oct 21.

Intestinal endometriosis mimicking carcinoma of rectum and sigmoid colon: a report of five cases.

Kim JS, Hur H, Min BS, Kim H, Sohn SK, Cho CH, Kim NK.

Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.

Among women with intestinal endometriosis, the sigmoid colon and rectum are the most commonly involved areas. Sometimes, the differential diagnosis of colorectal endometriosis from carcinoma of the colon and rectum is difficult due to similar colonoscopic and radiologic findings. From October 2002 to September 2007, we performed five operations with curative intent for rectal and sigmoid colon cancer that revealed intestinal endometriosis. Colonoscopic and radiologic findings were suggestive of carcinoma of rectum and sigmoid colon, such as rectal cancer, sigmoid colon cancer and gastrointestinal stromal tumor (GIST). Anterior resection was performed in two patients, low anterior resection was performed in one patient and laparoscopic low anterior resection was done in two patients. We suggest to consider also intestinal endometriosis in reproductive women presenting with gastrointestinal symptoms and an intestinal mass of unknown origin.

Fertil Steril. 2009 Oct 28. [Epub ahead of print]

Association of G1057D variant of insulin receptor substrate-2 with endometriosis.

Cayan F, Ertunç D, Aras-Ateş N, Ayaz L, Akbay E, Karakaş S, Coban O, Dilek S.

Departments of Obstetrics and Gynecology, University of Mersin School of Medicine, Mersin, Turkey.

OBJECTIVE: To investigate whether the insulin receptor substrate (IRS)-2 G1057D polymorphism is associated with the risk of endometriosis, and to evaluate potential correlation of IRS2 gene polymorphism with the stages of endometriosis. DESIGN: Case-control study. SETTING: Gynecology clinics in university hospital. PATIENT(S): Women with (n = 135) or without (n = 135) endometriosis. Afterward, the women with endometriosis were divided into two groups according to the stage: group 1 included 63 women in stages I-II, and group 2 included 72 women in stages III-IV. INTERVENTION(S): Genotyping by polymerase chain reaction-based restriction fragment-length polymorphism method. MAIN OUTCOME MEASURE(S): Genotype distribution of the G1057D polymorphism in the IRS2 gene. RESULT(S): The genotype distribution of the IRS2 G1057D polymorphism in the endometriosis group was significantly different from that of the control group (GG/GD/DD rates were 43.0%/39.3%/17.7% and 55.6%/36.3%/8.1% for the endometriosis and control groups, respectively). Further subgroup analyses according to the stage of endometriosis also revealed a positive association between the IRS2 DD genotype expression and stage III-IV endometriosis patients in the population studied. CONCLUSION(S): These results suggest that the IRS2 G1057D polymorphism may be associated with an increased risk for endometriosis.

Fertil Steril. 2009 Oct 28. [Epub ahead of print]

The effects of letrozole and melatonin on surgically induced endometriosis in a rat model: a preliminary study.

Yildirim G, Attar R, Ozkan F, Kumbak B, Ficicioglu C, Yesildaglar N.

Center for Reproductive Medicine, Department of Obstetrics, and Gynecology, Yeditepe University Hospital, Istanbul, Turkey.

OBJECTIVE: To determine the effects of letrozole and melatonin on surgically induced endometriosis in a rat endometriosis model. DESIGN: Prospective, randomized, controlled, experimental study. SETTING: Experimental Research Center of Yeditepe University (YUDETAM). ANIMAL(S): Thirty female, nonpregnant, nulligravid Wistar-Hannover albino rats. INTERVENTION(S): Surgical induction of endometriosis, administration of estrogen for 2 weeks, and laparotomy; administration of letrozole or melatonin for 2 weeks after induction of endometriosis, and laparotomy; administration of estrogen for 2 weeks and necropsy. MAIN OUTCOME MEASURE(S): The volume and histopathologic scores of endometriotic foci, and levels of superoxide dismutase, catalase, and malondialdehyde in the peritoneal fluid. RESULT(S): The mean volumes of the endometriotic foci were 99.6 +/- 18.8 mm(3), 21.5 +/- 7.4 mm(3), and 29.2 +/- 17.5 mm(3), and histopathologic scores were 2.5 +/- 0.7, 2.0 +/- 0.8, and 1.7 +/- 0.9 in the melatonin group at the end of the second, fourth, and sixth weeks, respectively. The mean volumes of the endometriotic foci were 75.9 +/- 26.3 mm(3), 29.8 +/- 14.7 mm(3), and 121.2 +/- 35.1 mm(3) and the histopathologic scores were 2.5 +/- 0.5, 2.2 +/- 0.8, and 2.7 +/- 0.4 in the letrozole group at the end of the second, fourth, and sixth weeks, respectively. In the melatonin group, peritoneal fluid superoxide dismutase and catalase levels increased statistically significantly. CONCLUSION(S): Melatonin caused more pronounced regression of endometriotic foci when compared with letrozole in a rat model. After the cessation of melatonin treatment, the recurrence rate was lower than that observed after the cessation of letrozole treatment.

Reprod Biol Endocrinol. 2009 Oct 30;7(1):123. [Epub ahead of print]

Quantity and quality of retrograde menstruation: a case control study.

Bokor A, Debrock S, Drijkoningen M, Goossens W, Fulop V, D’Hooghe T.

ABSTRACT: BACKGROUND: The purpose of this study was to test the hypothesis that menstruation is associated with a higher concentration of endometrial cells in peritoneal fluid(PF) and with increased white and red blood cell concentration in PF when compared to nonmenstrual phases of the cycle. METHODS: PF was obtained at laparoscopy from 107 women with endometriosis (n= 59) and controls with a normal pelvis (n= 48) during the luteal (n=46), follicular (n=38) or menstrual (n=23) phase of the cycle. Endometriosis was classified according to the classification of the American Society for Reproductive Medicine (rAFS into minimal (n=25), mild(n=20), moderate(n=6) and severe(n=8) disease. Cell counts (leucocytes, erythrocytes, thrombocytes) were determined on a cell counter. In a subset of 32 patients (13 controls and 19 women with endometriosis), PF was fixed, processed and thinlayers were prepared and stained with Papanicolaou method and with immunocytochemistry using monoclonal antibodies against cytokeratin 7(CK 7), CK 8/18, Ber-Ep4, vimentin, calretinin and CD68. Ber-Ep4 is a marker for cells with epithelial origin (in some cases for mesothelial cells as well). CD68 is specific for cells from monocyte/macrophage lineage; CK7 and CK8/18 are markers for both endometrial epithelial and mesothelial cells, whereas calretinin and vimentin are markers for both endometrial stromal and mesothelial cells. RESULTS: In comparison with the nonmenstrual phase of the cycle, analysis of PF during menstruation showed an increased concentration of leucocytes (3.3×109/L vs 0.8×109/L, P = 0.03), erythrocytes (0.3×1012/L vs 0.02×1012/L, P = 0.006), hematocrit (0.03 L/L vs 0.003 L/L, P = 0.01) and hemoglobin (0.8 g/dL vs 0.1 g/dL, P = 0.01). Mesothelial cells stained positively with CK7, CK8/18, vimentin, and calretinin. Cells positive for Ber-Ep4 were not observed, except in 2 patients with endometriosis investigated during menses. In all patients 50-98% of single cells were strongly positive for both vimentin and CD68. CONCLUSIONS: When compared to nonmenstrual phases of the cycle, menstruation is associated with an increased concentration of red and white blood cells in PF. However, the presence of EM cells that are detectable by immunohistochemistry in PF is low during all phases of the cycle, including menstruation.

Acta Obstet Gynecol Scand. 2009 Nov 2. [Epub ahead of print]

+1730 G/A polymorphism of the estrogen receptor beta gene (ERbeta) may be an important genetic factor predisposing to endometriosis.

Bianco B, Christofolini DM, Mafra FA, Brandes A, Zulli K, Barbosa CP.

Division of Genetics and Human Reproduction – Department of Gynecology and Obstetrics, ABC Faculty of Medicine, Santo André, São Paulo, Brazil.

Abstract Objective. To determine the frequency of the estrogen receptor gene (ERbeta) +1730 G/A polymorphism in Brazilian women with endometriosis. Design. Case-control study. Setting. Endometriosis Outpatient Clinic and Family Planning Outpatient Clinic of ABC Faculty of Medicine. Population. A total of 108 patients with endometriosis and a control group consisting of 210 fertile women. Methods. The ERbeta gene +1730 G/A polymorphism was identified by restriction fragment length polymorphism-polymerase chain reaction. Main outcome measure(s). Genotype distribution and allele frequency of the +1730 G/A polymorphism in the ERbeta gene. Results. Genotypes GG, GA and AA of the ERbeta gene presented frequencies of 50.9%, 47.2% and 1.9%, respectively, in the women with endometriosis. Among the patients with stage I/II endometriosis, 47% presented the normal homozygous genotype GG; 51% had a GA heterozygous genotype and 2% had a homozygous mutated genotype AA. Among the patients with stage III/IV endometriosis, genotypes GG, GA and AA were present in 54.3%, 44% and 1.7%, respectively. In the control group, 74.3% presented the normal homozygous genotype GG, 24.3% the heterozygous genotype GA and 1.4% the homozygous mutated genotype AA. Conclusion. The data suggest that the ERbeta gene +1730 G/A polymorphism can be associated with the risk of endometriosis development, regardless of the stage of the disease.

Appl Immunohistochem Mol Morphol. 2009 Oct 28. [Epub ahead of print]

Steroidogenic Factor-1 Expression in Ovarian Endometriosis.

Noël JC, Borghese B, Vaiman D, Fayt I, Anaf V, Chapron C.

*Department of Gynecopathology, Erasme University Hospital, Free University of Brussels, Belgium daggerINSERM, U567 double daggerCNRS, UMR8104, Institut Cochin section signUniversité Paris Descartes, Faculté de Médecine, Hôpital Cochin parallelService de Gynécologie-Obstétrique 2 et Médecine de la Reproduction, CHU Cochin Saint-Vincent de Paul, Assistance Publique-Hôpitaux de Paris, Paris, France.

Steroidogenic factor-1 (SF-1), a major protein regulating the complex cascade of steroidogenis, has been postulated to play a role in ovarian endometriosis. However, the expression in situ of SF-1 in ovarian endometriosis is unknown. To shed light on its presence, the expression of SF-1 was studied by immunohistochemistry in 30 cases of ovarian endometriosis (proliferative, n=15; secretory phase, n=15) and in 10 cases of normal eutopic endometrium coming from the same patients. No SF-1 immunoreactivity was observed in glands or endometrial stroma from ovarian endometriosis or eutopic endometrium. In contrast, a strong immunoreactivity was observed in the adjacent ovarian cortical or medullary mesenchymatous cells in all the cases examined independently of the cycle’s phases. Contrary to the earlier reported hypothesis, our data showed for the first time the absence of SF-1 expression in glands and endometrial stroma from ovarian endometriosis and eutopic endometrium. However, the strong expression of SF-1 observed in cortical and medullary ovarian mesenchymatous cells adjacent to endometriosis, suggests a potential role for these cells in locally induced steroidogenesis.

BJOG. 2009 Oct 29. [Epub ahead of print]

The menstrual disorder of teenagers (MDOT) study: determining typical menstrual patterns and menstrual disturbance in a large population-based study of Australian teenagers.

Parker MA, Sneddon AE, Arbon P.

Australian National University Medical School, Garran, Canberra, Australia.

Objective The aim of this study was to: (1) establish the typical experience of menstruation for senior high school girls and (2) determine how many experience considerable menstrual disturbance that could require further investigation and management of underlying pathology. Design Cross-sectional study. Setting Senior High Schools in the Australian Capital Territory (ACT), Australia. Population A total of 1051 girls aged between 15 and 19 years. Methods Data based on a quantitative survey. Main outcome measures Self-reports of menstrual bleeding patterns, typical and atypical symptoms and morbidities. Results Typical menstruation in adolescence includes pain (93%), cramping (71%), premenstrual symptoms (96%) and mood disturbance (73%). Highly significant associations were found between increasing severity of menstrual pain, number of menstrual-related symptoms, interference with life activities and school absence. These associations indicate that approximately 25% of the sample had marked menstrual disturbance: 21% experienced severe pain; 26% school absence; 26% suffering five or more symptoms; >/=24% reporting moderate to high interference with four out of nine life activities. Approximately 10% reported atypical symptoms associated with menstruation. Diagnosis of menstrual pathology in the sample was low, even though 33% had seen a GP and 9% had been referred to a specialist. Conclusions Menstrual pain and symptoms are common in teenagers. Girls indicating moderate to severe pain in association with a high number of menstrual symptoms, school absence and interference with life activities should be effectively managed to minimise menstrual morbidity. Those girls who do not respond to medical management should be considered for further investigation for possible underlying pathology, such as endometriosis.

Can J Surg. 2009 Oct;52(5):444-5.

Incisional endometriosis: a report of 3 cases.

Sengul I, Sengul D, Kahyaoglu S, Kahyaoglu I.

Department of General Surgery, Giresun University Faculty of Medicine, Giresun, Turkey. dr.ilker52@mynet.com

Clin Nephrol. 2009 Nov;72(5):418-9.

Hydroureteronephrosis caused by endometriosis around the ureter.

Lee TH, Kim W, Lee S, Kang KP, Kim YK, Kim MK, Jeong YB, Park HS, Lee NH, Park SK.

Eur Radiol. 2009 Oct 28. [Epub ahead of print]

Utility of vaginal and rectal contrast medium in MRI for the detection of deep pelvic endometriosis.

Chassang M, Novellas S, Bloch-Marcotte C, Delotte J, Toullalan O, Bongain A, Chevallier P.

Service d’Imagerie diagnostique et interventionnelle, Centre Hospitalier Régional et Universitaire de Nice, Hôpital Archet 2, 151 route de Saint Antoine de Ginestière, B.P. 3079, 06202, Nice Cedex 3, France.

OBJECTIVE: To study the sensitivity of MRI performed utilising vaginal and rectal opacification with ultrasound gel in the detection of deep pelvic endometriosis. MATERIAL AND METHODS: This was a prospective monocentric study. All patients evaluated by the gynaecologist for pelvic pain, endometriosis or infertility were included. Axial and sagittal T2-weighted images were performed both with and without vaginal and rectal opacification with ultrasound gel. Three radiologists, all blinded, interpreted the images with a minimum of 15 days between the two readings. MRI performance with and without vaginal and rectal opacification was evaluated by calculating sensitivity, specificity and both positive and negative predictive values. RESULTS: Seventy-eight patients were included. Among these, 31 patients had deep pelvic endometriosis of which 24 were confirmed by laparoscopy. Seventy-six locations of deep pelvic endometriosis were discovered on MRI. For the three reviewers there was a significant improvement in sensitivity between pre- and post-contrast MRI (p < 0.0002). CONCLUSION: Opacification of the vagina and rectum significantly improved the sensitivity of MRI for the detection of deep pelvic endometriosis by expanding the vagina and rectum, thus allowing better delineation of the pelvic organs. This was especially apparent for lesions localised to the vagina and rectovaginal septum.

J Ethnopharmacol. 2009 Oct 24. [Epub ahead of print]

Fertility inducing effect of aerial parts of Coccinia cordifolia L. in female rats.

Jha U, Asad M, Asdaq SM, Das AK, Prasad VS.

Department of Pharmacology, Krupanidhi College of Pharmacy, 5 Sarjapur Road, Koramangala, Bangalore 560 034, India.

ETHNOPHARMACOLOGICAL RELEVANCE: The aerial parts of Coccinia cordifolia L. are used to treat female infertility in West Bengal state of India. AIM OF THE STUDY: The present study was undertaken to evaluate the fertility inducing effect of aerial parts of Coccinia cordifolia L. in female rats. MATERIALS AND METHODS: The effect of aqueous extract of Coccinia cordifolia L. on hyperprolactinemia induced infertility, endometriosis induced infertility and androgen-induced infertility was studied. The effect on serum estrogen level, serum progesterone level and reproductive tract was also evaluated in normal healthy female rats. The extract was administered orally at two different doses of 500mg/kg and 1000mg/kg. RESULTS: In hyperprolactinemia induced infertility model, the numbers of uterine implants were almost 10 times more in the extract treated groups as compared to control. The high dose of extract also produced a significant increase in serum estrogen levels (p<0.01) and number of corpus luteum (p<0.05) in healthy female rats. The extract at both doses was effective in reducing the weight of endometrial implants by 70-80%, but failed to induce fertility in rats with endometriosis. The extract was ineffective in inducing fertility in androgen-induced infertility model. CONCLUSIONS: The aqueous extract of Coccinia cordifolia L. induces fertility in hyperprolactinemia induced infertility model in female rats.

Ned Tijdschr Geneeskd. 2009;153. pii: B430.

Loss of renal function due to deep infiltrating endometriosis; a complicated consideration in women who wish to have children.

[Article in Dutch]

de Graaff AA, Beets-Tan RG, Beets GL, van de Beek CK, Dunselman GA.

Maastricht Universitair Medisch Centrum, Afd. Obstetrie en Gynaecologie, Maastricht, The Netherlands. aa.de.graaff@mumc.nl

Three nulliparous women, aged 39, 34 and 26 years, who were treated for fertility problems and who were affected by endometriosis, presented with ureteral obstruction caused by deep infiltrating endometriosis. The first two patients had complete unilateral loss of kidney function at the time of diagnosis. They chose to have fertility treatment first and both became pregnant. The third patient still had 24% renal function in the affected left kidney. She was treated by complete surgical resection of the endometriosis and reimplantation of the ureter. Ureteral obstruction is a rare, but serious, complication of deep infiltrating endometriosis. Timely recognition is important, since delay results in unnoticed loss of renal function. Clinical investigation for endometriosis of the posterior vaginal fornix is recommended for all patients with chronic abdominal pain, severe dysmenorrhoea or deep dyspareunia. On diagnosis of deep infiltrating endometriosis, further examination is necessary to detect possible ureteral obstruction and consequent hydronephrosis, which can be demonstrated by ultrasound. MRI is of value to map the extent of disease, which is usually multi-focal. Surgery to relieve ureteral obstruction and remove all endometriotic lesions is the treatment of choice if the kidney is still functional.

Int J Clin Oncol. 2009 Oct;14(5):383-91. Epub 2009 Oct 25.

Ovarian cancer in endometriosis: molecular biology, pathology, and clinical management.

Mandai M, Yamaguchi K, Matsumura N, Baba T, Konishi I.

Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Sakyo-ku, Kyoto, Japan. mandai@kuhp.kyoto-u.ac

Recent molecular and pathological evidence suggests that endometriosis is a monoclonal, neoplastic disease. Moreover, endometriosis serves as a precursor of ovarian cancer (endometriosis-associated ovarian cancer; EAOC), especially of the endometrioid and clear cell subtypes. Although a variety of molecular events, such as p53 alteration, PTEN silencing, K-ras mutations, and HNF-1 activation, have been identified in EAOC, its precise carcinogenic mechanism remains poorly understood. Our recent data indicate that microenvironmental factors, including oxidative stress and inflammation, play an important role in the carcinogenesis and phenotype of EAOC. The management of endometriosis from the standpoint of EAOC is not standardized yet. To this end, clarification of the precise natural course and the risk factors that contribute to malignant transformation remain important goals. Among the phenotypes of EAOC, clear cell carcinoma, seems to require a specific treatment strategy, including molecular targeting.

Int J Clin Oncol. 2009 Oct;14(5):378-82. Epub 2009 Oct 25.

Ovarian cancer in endometriosis: epidemiology, natural history, and clinical diagnosis.

Kobayashi H.

Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, Nara, Japan. hirokoba@naramed-u.ac.jp

We review whether endometriosis-associated ovarian cancer is a specific entity compared with ovarian cancer not associated with endometriosis, with respect to epidemiology, natural history, and clinical diagnosis; we present a review of the English-language literature for ovarian cancer in endometriosis with respect to these three features. A recent prospective study in Japan directly showed that, during a follow-up of up to 17 years of an ovarian endometrioma cohort (n = 6398), 46 incident ovarian cancers were identified, showing that the ovarian cancer risk was significantly elevated in patients with ovarian endometrioma (standardized incidence ratio [SIR], 8.95; 95% confidence interval [CI], 4.12 to 15.3). Advancing age (>40 years) and the size of the endometriomas (>9 cm) were independent predictors of the development of ovarian cancer among the women with ovarian endometrioma. Although some endometriosis lesions may predispose to clear cell carcinoma (CCC) and endometrioid adenocarcinoma (EAC) of the ovary, both of these cancers differ from the other histological types with respect to their clinical characteristics and carcinogenesis. In patients with endometriosis-associated ovarian cancer, benign-appearing ovarian masses are typically present several years before the diagnosis of the cancer. A slightly elevated carbohydrate antigen [CA] 125 level is also typically present many years before the diagnosis in these patients. However, serous-type ovarian cancer may exhibit a rapid progression possibly through de-novo carcinogenesis. Ovarian endometrioma could be viewed as a neoplastic process, particularly in perimenopausal women. Understanding the mechanisms of the development of endometriosis and elucidating its pathogenesis and pathophysiology are intrinsic to the prevention of endometriosis-associated ovarian cancer and the search for effective therapies.

Int J Clin Oncol. 2009 Oct;14(5):377. Epub 2009 Oct 25.

Ovarian cancer in endometriosis.

Konishi I.

Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Sakyo-ku, Kyoto, Japan. konishi@kuhp.kyoto-u.ac.jp

Virchows Arch. 2009 Oct 24. [Epub ahead of print]

Aberrant expression of p27(Kip1)-interacting cell-cycle regulatory proteins in ovarian clear cell carcinomas and their precursors with special consideration of two distinct multistage clear cell carcinogenetic pathways.

Yamamoto S, Tsuda H, Miyai K, Takano M, Tamai S, Matsubara O.

Department of Basic Pathology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan.

We have previously reported that alterations of p27(Kip1)-interacting cell-cycle proteins frequently occur during the development of endometriosis-associated ovarian clear cell adenocarcinoma (CCA; Yamamoto et al., Histopathology in press, 20). However, CCA also occurs in association with clear cell adenofibroma (CCAF). In this study, the expressions of p27(Kip1)-interacting proteins, i.e., p27(Kip1), Skp2, Cks1, cyclin A, cyclin E, and the Ki-67 labeling index (LI), were analyzed in 25 CCAFs (11 benign and 14 borderline) and 15 CCAF-associated CCAs, and compared with the expression status of each protein in the 23 previously studied endometriosis-associated CCAs. Although aberrant expression of all p27(Kip1)-interacting proteins was more frequent in the CCAF-associated CCAs than in the benign CCAFs, statistical significance was found only for Cks1 overexpression. The frequencies of p27(Kip1) downregulation and overexpression of Skp2 and cyclin A were significantly lower in CCAF-associated than in endometriosis-associated CCAs (P < 0.05, respectively). The frequencies of p27(Kip1) downregulation and Skp2 overexpression in borderline CCAFs were significantly lower than those in atypical endometriosis components in endometriosis-associated CCAs (P < 0.05, respectively). Mean Ki-67 LI increased significantly through benign (4.9%) to borderline (11.1%) CCAF and to CCAF-associated CCA (30.6%), but the latter two values were significantly lower than those in atypical endometriosis (21.4%) and endometriosis-associated CCA (46.9%; P < 0.05, respectively). These data suggest that accumulated alterations of p27(Kip1)-interacting proteins may accelerate the development of CCAs regardless of their carcinogenetic pathways, but that tumor cells in the CCAF-associated pathway appear to show slower cell-cycle progression than those in the endometriosis-associated pathway, possibly accounting for the distinct clinicopathological features of the two CCA subtypes.

Braz J Med Biol Res. 2009 Nov;42(11):1039-43.

Peritoneal and serum interleukin-18 levels are not increased in women with minimum or mild endometriosis.

Glitz C, Souza CA, Rodini GP, Genro V, Bilibio JP, Senger M, Cunha-Filho JS.

Departamento de Obstetrícia e Ginecologia, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil.

Interleukin-18 (IL-18) is a cytokine that belongs to the IL-1 family. Endometriosis is strongly associated with sub-fertility, and affects about 15% of women of reproductive age. IL-18 may favor the progression of endometriosis. The objective of the present study was to determine the concentration of IL-18 in the serum and peritoneal fluid of infertile women with endometriosis. Forty infertile and 25 fertile women were screened in a teaching hospital. Thirty-four infertile patients with minimal or mild endometriosis and 22 fertile controls were enrolled in the study. The primary outcome was the estimate of IL-18 levels and the secondary outcome was the correlation between serum and peritoneal levels of IL-18. There were no differences between the two groups regarding age, body mass index and levels of peritoneal fluid IL-18 (mean +/- SD): 290.85 +/- 173.02 pg/mL for infertile women vs 374.21 +/- 330.15 pg/mL for controls; or serum IL-18: 391.07 +/- 119.71 pg/mL for infertile women vs 373.42 +/- 129.11 pg/mL for controls. However, a positive association was found between serum and peritoneal IL-18 levels in patients with endometriosis: r = 0.794, P = 0.0001. All measurements were carried out at the same time by the Human IL-18 Immuno Assay ELISA kit (MBL Co. Ltd., Japan). The present study did not find evidence supporting the hypothesis that IL-18 levels are associated with infertility in women with minimal and mild endometriosis, although a positive correlation was detected in these women between peritoneal and serum levels of IL-18.

Hum Reprod. 2009 Oct 24. [Epub ahead of print]

The relative contribution of IVF to the total ongoing pregnancy rate in a subfertile cohort.

Brandes M, Hamilton CJ, de Bruin JP, Nelen WL, Kremer JA.

Department of Obstetrics and Gynaecology, Jeroen Bosch Ziekenhuis, PO Box 90153, 5200 ME ‘s-Hertogenbosch, The Netherlands.

BACKGROUND Although in vitro fertilization (IVF) was introduced more than 30 years ago, its exact role in the spectrum of fertility treatments has never been studied in an unselected population. The aim of this study was to visualize the contribution of IVF to the ongoing pregnancy rates in a cohort of newly referred subfertile couples. MATERIALS All new subfertile couples (n = 1391) that were referred to our fertility clinic by their general practitioner between January 2002 and December 2006 were included. Fertility care was provided according to the national Dutch fertility guidelines. Data on diagnosis, treatment, mode of conception and pregnancy outcome were documented. If follow-up data were missing, couples were contacted. Cumulative pregnancy curves were constructed for the whole cohort and per diagnostic group. RESULTS As per December 2008 the overall ongoing pregnancy rate was 72.0% (n = 1001). Almost half of the pregnancies were conceived spontaneously (45.6%), 19.2% after ovulation induction (OI), 14.0% after intrauterine insemination (IUI) and 21.2% after IVF. A quarter (n = 349) of couples received IVF treatment, which was successful in 60% of cases. IVF had the largest contribution to ongoing pregnancies in patients with ‘tubal factor’, ‘endometriosis’ and ‘male factor’ (45, 45 and 37%, respectively) while in couples with ‘unexplained subfertility’ and ‘ovulation disorders’ the contribution to ongoing pregnancies of IVF was limited (13 and 4.5%, respectively). CONCLUSIONS In a cohort of subfertile couples, most pregnancies were conceived spontaneously. The contribution of IVF to ongoing pregnancy rates was comparable to those of OI and IUI. Compared with the pre-IVF era, couples with ‘endometriosis’, ‘tubal factor’ and ‘male subfertility’ have benefited most from its introduction.

Acta Obstet Gynecol Scand. 2009 Oct 23. [Epub ahead of print]

Laparoscopic treatment of diaphragmatic endometriosis causing chronic shoulder and arm pain.

Cucinella G, Granese R, Calagna G, Candiani M, Perino A.

Department of Obstetrics and Gynecology, University Hospital ‘Paolo Giaccone’, Palermo, Italy.

Int J Gynecol Pathol. 2009 Nov;28(6):584-8.

Ovarian clear cell carcinoma arising in a mucinous cystadenoma.

Wani Y, Notohara K.

Department of Pathology, Kurashiki Central Hospital, Miwa, Kurashiki 710-8602, Japan. yw7144@kchnet.or.jp

Here we report a rare case of ovarian clear cell carcinoma (CC) arising in a mucinous cystadenoma. A 59-year-old woman presented with a dull pain at the left inguinal area. She was found to have a left ovarian cyst measuring 4.7 cm and underwent a salpingo-oophorectomy. The unilocular cyst contained thick mucin, lacking any solid components. Histopathologically, most of the cyst wall was lined with a single layer of tall columnar cells with basophilic mucin. Within limited areas, small glands consisting of clear cytoplasm aggregated and intermingled with or partially transitioned to the mucinous glands. The clear cell components had adenofibroma-like features devoid of significant nuclear atypia or stromal invasion, including distinctive foci of CC with a hobnail appearance and hyperchromatic nuclei surrounded by desmoplastic or hyalinized stroma. Immunohistochemically, both mucinous and clear cells were positive for estrogen receptor. Hepatocyte nuclear factor-1beta and laminin were positive in all of the clear cell components, in contrast to a consistent lack of staining in the mucinous epithelium. An eleven-month follow-up revealed no recurrence or metastasis. This case was considered as an early manifestation of ovarian CC arising in a mucinous cystadenoma in the absence of demonstrable endometriosis.

Headache. 2009 Oct 21. [Epub ahead of print]

Childhood Maltreatment and Migraine (Part III). Association With Comorbid Pain Conditions.

Tietjen GE, Brandes JL, Peterlin BL, Eloff A, Dafer RM, Stein MR, Drexler E, Martin VT, Hutchinson S, Aurora SK, Recober A, Herial NA, Utley C, White L, Khuder SA.

University of Toledo College of Medicine, Toledo, OH, USA (G.E. Tietjen, N.A. Herial, C. Utley, L. White, and S.A. Khuder); Nashville Neuroscience Group, Nashville, TN, USA (J.L. Brandes); Drexel University College of Medicine, Philadelphia, PA, USA (B.L. Peterlin); University of Calgary, Calgary, AB, Canada (A. Eloff); Loyola University Medical Center, Maywood, IL, USA (R.M. Dafer); John Muir Medical Center, Walnut Creek, CA, USA (M.R. Stein); Maimonides Medical Center, Brooklyn, NY, USA (E. Drexler); University of Cincinnati, Cincinnati, OH, USA (V.T. Martin); Orange County Migraine & Headache Center, Irvine, CA, USA (S. Hutchinson); Swedish Headache Center, Seattle, WA, USA (S.K. Aurora); University of Iowa, Iowa City, IA, USA (A. Recober).

(Headache 2009;**:**-**) Objective.- To evaluate in a headache clinic population the relationship of childhood maltreatment on the prevalence of pain conditions comorbid with migraine. Background.- Childhood maltreatment is highly prevalent and has been frequently associated with recurrent headache. The relationship of maltreatment and pain has, however, been a subject of some debate. Methods.- Cross-sectional data on self-reported physician-diagnosed pain conditions were electronically collected from persons with migraine (diagnosed according to International Classification of Headache Disorders-2), seeking treatment in headache clinics at 11 centers across the US and Canada. These included irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS), fibromyalgia (FM), interstitial cystitis (IC), arthritis, endometriosis, and uterine fibroids. Other information included demographics, migraine characteristics (frequency, headache-related disability), remote and current depression (The Patient Health Questionnaire-9), and remote and current anxiety (The Beck Anxiety Inventory). Patients also completed the Childhood Trauma Questionnaire regarding sexual, emotional, and physical abuse, and emotional and physical neglect under the age of 18 years old. Statistical analyses accounted for the survey design and appropriate procedures in SAS such as surveymeans, surveyfreq, and surveylogistic were applied to the weighted data. Results.- A total of 1348 migraineurs (88% women) were included in this study (mean age 41 years). Based on physician diagnosis or validated criteria, 31% had IBS, 16% had CFS, and 10% had FM. Diagnosis of IC was reported by 6.5%, arthritis by 25%, and in women, endometriosis was reported by 15% and uterine fibroids by 14%. At least 1 comorbid pain condition was reported by 61%, 2 conditions by 18%, and 3 or more by 13%. Childhood maltreatment was reported by 58% of the patients. Emotional abuse was associated with increased prevalence of IBS, CFS, arthritis, and physical neglect with arthritis. In women, physical abuse was associated with endometriosis and physical neglect with uterine fibroids. Emotional abuse, and physical abuse and neglect (P < .0001 for all) were also associated with increased total number of comorbid conditions. In ordinal logistic regression models, adjusted for sociodemographics and current depression (prevalence 28%) and anxiety (prevalence 56%), emotional abuse (odds ratios [OR] = 1.69, 95% confidence intervals [CI]: 1.224-2.33) and physical neglect (OR = 1.73, 95% CI: 1.22-2.46) were independently associated with an increased number of pain conditions. The cohort of women, similarly, had associations of emotional abuse (OR = 1.94, 95% CI: 1.40-2.72) and physical neglect (OR = 1.90, 95% CI: 1.34-2.68) with an increased number of pain comorbidities. Conclusion.- The association of childhood maltreatment and pain was stronger in those reporting multiple pain conditions and multiple maltreatment types. This finding suggests that in migraineurs childhood maltreatment may be a risk factor for development of comorbid pain disorders.

Anesth Analg. 2009 Nov;109(5):1688-90.

Central sensory-motor deficit after uneventful single-dose spinal morphine administration in a patient with preexisting migraine headaches.

Lentschener C, Dousset B, Zuber M, Ozier Y.

Department of Anesthesia and Critical Care, Faculté de Médecine, Université Paris-Descartes, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Paris, France. claude.lentschener@cch.aphp.f.

Hemiplegic migraine is a condition associated with vascular alteration of the central nervous system and transient neurologic deficits. Permanent morphine-induced motor dysfunction has been reported after spinal ischemia. We report a persisting central neurological deficit after single-dose spinal administration of 400 microg of morphine in a patient with no previous neurological condition. Hemiplegic migraine was thought to be present when the patient emerged from anesthesia. Weakness in the left quadriceps and saddle anesthesia of the perineum and urinary retention of central origin remained present 3 yr later. Over the 3 postoperative years, the patient was admitted to a neurological unit 5 times because of acute headache associated with complete left-sided hemiplegia. These symptoms resolved within 24 h of onset. Hemiplegic migraine was thought to be the most likely diagnosis of these recurrent attacks. We hypothesize that the patient’s persistent deficits were caused by a combination of spinal morphine and spinal cord vascular dysfunction associated with hemiplegic migraine.

Dis Model Mech. 2009 Nov-Dec;2(11-12):593-603. Epub 2009 Oct 19.

A conditional mouse model for human MUC1-positive endometriosis shows the presence of anti-MUC1 antibodies and Foxp3+ regulatory T cells.

Budiu RA, Diaconu I, Chrissluis R, Dricu A, Edwards RP, Vlad AM.

Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine and Magee Womens Research Institute, Pittsburgh, PA 15213, USA.

Endometriosis is defined by the presence of tissue implants resembling endometrial glands outside of the uterus, at ectopic sites, frequently on the ovarian surface. The ectopic lesions are often invasive, resistant to therapy, and may predispose to endometrioid and clear cell ovarian tumors. The complex mechanisms leading to chronic endometriosis are mediated partly by impaired immune surveillance in the host. Although innate immunity has been addressed previously, the response of adaptive immune effectors to specific antigens has not been characterized, mostly because very few endometriosis antigens have been defined to date. We postulated that the mucin 1 (MUC1) glycoprotein, which is normally present on eutopic human endometrial glands and overexpressed in endometrioid and clear cell ovarian tumors, is also present in ectopic lesions of ovarian endometriosis. Furthermore, changes in MUC1 expression in endometriosis could promote adaptive anti-MUC1 immunity that might play a role in the malignant progression. To test our hypothesis, we crossed MUC1 transgenic mice, which express human MUC1 under the endogenous promoter, with the loxP-Stop-loxP-Kras(G12D/+) (Kras) mice, in which endometriosis can be induced through Cre-loxP recombination. The double transgenic MUC1Kras mice develop benign, MUC1-positive ovarian lesions, closely resembling human endometriosis. Subsequent to disease induction, the mice generate high titers of IgM and IgG antibodies that are specific for MUC1. Antibodies appear early in disease and the predominance of the IgG1 subclass suggests Th2-driven immunity. Immune phenotyping revealed an accumulation of Foxp3+ CD4 regulatory T cells (Tregs) in the draining lymph nodes at late-stage disease. Furthermore, our observations in human endometriosis showed a similar recruitment of FOXP3+ CD4 T cells. Overall, our results reveal a Th2/Treg-dominant natural immunity in endometriosis with potential implications for cancer progression.

Rev Bras Ginecol Obstet. 2009 Jul;31(7):349-52.

Evaluation of basal FSH serum levels in infertile patients with deep ovarian endometriosis who underwent surgery.

[Article in Portuguese]

Frankfurt S, Nunes AL, Reis AD, Christofolini DM, Bianco B, Barbosa CP.

Médica Residente da Disciplina de Ginecologia Patológica e Reprodução Humana–FMABC-Santo André (SP), Brasil.

PURPOSE: to evaluate the ovarian reserve of infertile patients with severe ovarian endrometriosis, submitted to excisional surgery of endometriomas and attended from February to November, 2008. METHODS: prospective study, including 30 patients with endometriosis grades III and IV, with severe ovarian impairment, submitted to excisional surgery of the endometriomas, and 30 patients with endometriosis grades I and II, allocated as a Control Group. The ovarian reserve was indirectly assessed, through the basal (U/L) follicle stimulating hormone (FSH), between the third and fifth days of the cycle, 12 months after the surgery. The body mass index (BMI) was calculated according to Quetelet’s formula [weight (kg)/height(cm(2))]. The Mann-Whitney non-parametric U test was used to compare the variables ‘age’, ‘BMI’ and ‘basal SFH’ between the groups. RESULTS: there was no significant difference between the groups about age and BMI. Concerning basal FSH, in the group of patients with severe endometriosis, the average value was 7.0 U/L, while in the Control Group, it was 5.6 U/L (p=0.3), what demonstrates that the difference between the two groups was not significant. CONCLUSIONS: the surgery did not affect the ovarian reserve of patients with severe ovarian endometriosis.

J Urol. 2009 Dec;182(6):2748-52. Epub 2009 Oct 17.

Laparoscopic management of ureteral endometriosis: the Stanford University hospital experience with 96 consecutive cases.

Bosev D, Nicoll LM, Bhagan L, Lemyre M, Payne CK, Gill H, Nezhat C.

Department of Urology, Stanford University Medical Center, Palo Alto, California 94304, USA.

PURPOSE: We report the clinical characteristics and the principles of laparoscopic management of ureteral endometriosis at our institution. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients with ureteral endometriosis. RESULTS: Preoperatively 97% of patients complained of pain but only a third had urinary symptoms. The left ureter was affected in 64% of cases and disease was bilateral in 10%. Four patients had hydroureter and 2 had hydronephrosis. CONCLUSIONS: To our knowledge this report represents the largest series of laparoscopically treated, pathologically confirmed ureteral endometriotic cases to date. It confirms that laparoscopic diagnosis and management of ureteral endometriosis are safe and efficient. All patients who undergo laparoscopy for endometriosis should be evaluated for possible ureteral involvement regardless of the presence or absence of urinary symptoms, or prior radiological evaluation since undiagnosed ureteral disease may result in loss of renal function.

Trends Endocrinol Metab. 2009 Oct 15. [Epub ahead of print]

Lysophosphatidic acid (LPA) signaling in vertebrate reproduction.

Ye X, Chun J.

Department of Physiology and Pharmacology, College of Veterinary Medicine, and Interdisciplinary Toxicology Program, University of Georgia, Athens, GA 30602, USA.

Lysophosphatidic acid (LPA) is a cell membrane phospholipid metabolite that can act as an extracellular signal. Its effects are mediated through at least five G protein-coupled receptors, LPA(1-5), and probably others as well. Studies in multiple species including LPAR-deficient mice and humans have identified or implicated important roles for receptor-mediated LPA signaling in multiple aspects of vertebrate reproduction. These include ovarian function, spermatogenesis, fertilization, early embryo development, embryo implantation, embryo spacing, decidualization, pregnancy maintenance and parturition. LPA signaling can also have pathological consequences, influencing aspects of endometriosis and ovarian cancer. Here we review recent progress in LPA signaling research relevant to female and male reproduction.

Fertil Steril. 2009 Oct 15. [Epub ahead of print]

Colorectal endometriosis: benefits of long-term follow-up in patients who underwent laparoscopic surgery.

Stepniewska A, Pomini P, Guerriero M, Scioscia M, Ruffo G, Minelli L.

Department of Obstetrics and Gynecology, Ospedale Sacro Cuore, Negrar (Verona), Italy.

In this retrospective cohort study, three groups of patients were included: 60 women who underwent endometriosis surgery with colorectal segmental resection, 40 women with surgical evidence of bowel endometriosis who underwent endometriosis removal without bowel resection, and 55 women affected by moderate or severe endometriosis with at least one endometrioma and deep infiltrating endometriosis but without bowel involvement. The results of a long-term ambulatory follow-up showed that if colorectal endometriosis was present, postoperative pain regression was more frequent, and among patients with bowel endometriosis the rate of recurrence was lower if segmental resection was performed.

Fertil Steril. 2009 Oct 14. [Epub ahead of print]

Lower limb compartment syndrome as a complication of laparoscopic laser surgery for severe endometriosis.

Tomassetti C, Meuleman C, Vanacker B, D’Hooghe T.

Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospitals Leuven, Leuven, Belgium.

OBJECTIVE: To report a case of lower limb compartment syndrome (LLCS) during long duration laparoscopic interventions for resection of extensive endometriosis, and evaluate the efficiency of a novel patient positioning method to reduce its prevalence. DESIGN: Case report and observational study. SETTING: University Hospitals, Belgium. PATIENT(S): Thirty-year-old woman undergoing a long duration laparoscopic intervention for resection of stage IV pelvic endometriosis. INTERVENTION(S): Laparoscopic intervention for resection of stage IV pelvic endometriosis. MAIN OUTCOME MEASURE(S): The occurrence of LLCS after laparoscopic surgery for extensive endometriosis, in this case, and the prevention of subsequent LLCS after the application of a novel patient positioning method including the following steps: maximal avoidance of the lithotomy position, patient positioning in a modified supine position, mobilization of the legs of the patient in between different surgical phases, and application of intermittent compression stockings. RESULT(S): The prevalence of lower limb compartment syndrome has been reduced to 0 since the application of the new patient positioning method. CONCLUSION(S): Lower limb compartment syndrome can be prevented in patients undergoing long duration multidisciplinary laparoscopic resection of extensive endometriosis by a novel sequential positioning method of patients before and during surgery.

J Minim Invasive Gynecol. 2009 Sep-Oct;16(5):649-51.

Laparoscopic treatment of acute ovarian incarceration into the pelvic peritoneal sac.

Kataoka K, Egami R, Izumi Y, Yamada Y, Egashira K, Miyahara A, Fukuhara M, Watanabe Y, Nakamura GI.

Department of Gynecology, Hamanomachi Hospital, Fukuoka, Japan. kataoka-k@hamanomachi.jp

Pelvic pain is a common symptom in women of reproductive age. Acute pelvic pain with rapid onset demands prompt diagnosis and treatment. We report the case of a patient with ovarian incarceration of acute onset. To our knowledge, this is the first report of ovarian incarceration into the pelvic peritoneal sac in a woman of reproductive age. In the present case, laparoscopy was useful in establishing the cause of pelvic pain. The patient reported severe lower right quadrant abdominal pain of sudden onset. At laparoscopic examination, the right fallopian tube was normal; however, the right ovary was not initially visible at the normal site. After the swollen right ovarian ligament was pulled aside using nontraumatic laparoscopic forceps, we were able to detect incarceration of the right ovary into the peritoneal sac in the medial to right uterosacral ligament. This case is unique because of ovarian incarceration into the peritoneal fenestration. We believe this condition was congenital because there was no other cause such as previous surgery, severe endometriosis, or pelvic inflammatory diseases.

J Minim Invasive Gynecol. 2009 Sep-Oct;16(5):618-21.

Vascular density of peritoneal endometriosis using narrow-band imaging system and vascular analysis software.

Kuroda K, Kitade M, Kikuchi I, Kumakiri J, Matsuoka S, Jinushi M, Shirai Y, Kuroda M, Takeda S.

Department of Obstetrics and Gynaecology, Juntendo University School of Medicine, Tokyo, Japan. arthur@juntendo.ac.jp

A pilot study was designed to analyze the vascular density of peritoneal endometriosis in 3 groups of lesions (red, black, and white) in 23 patients with peritoneal endometriosis who underwent laparoscopic surgery using the narrow-band imaging system and vascular analysis software. In the peritoneum, 21 red lesions were present in 10 patients, 12 black lesions were present in 9 patients, 12 white lesions were present in 8 patients, and 2 types of lesion were concomitantly present in 4 patients. Median vascular density of red, black, and white lesions under conventional light was 60.3%, 62.3%, and 60.6%, respectively, and under narrow-band light was 64.4%, 61.5%, and 62.0%, respectively, showing no significant differences among the lesions under either conventional or narrow-band light (p=.71 and p=.84, respectively). The median difference in vascular density under narrow-band and conventional light was not significantly different in black lesions (0.8%) or white lesions (1.0%); however, a difference of 4.5% was noted for red lesions (p <.001). We conclude that red lesions are indicative of early-stage endometriosis with angiogenesis. Use of the narrow-band system and vascular analysis software can enable accurate, objective, and reproducible evaluation of vascular density.

J Minim Invasive Gynecol. 2009 Sep-Oct;16(5):573-80.

Endometriosis of the diaphragm: four cases treated with a combination of laparoscopy and thoracoscopy.

Nezhat C, Nicoll LM, Bhagan L, Huang JQ, Bosev D, Hajhosseini B, Beygui RE.

Center for Special Minimally Invasive Surgery, Stanford University Medical Center, Palo Alto, California 94304, USA. Cnezhat@stanford.edu

STUDY OBJECTIVE: We aim to describe the clinical characteristics and the principles of combined laparoscopic and thoracoscopic management of women with diaphragmatic endometriosis at our institution. DESIGN: Case series (Canadian Task Force Classification II2). SETTING: Tertiary care referral center. PATIENTS: Four women with diaphragmatic endometriosis. INTERVENTIONS: Laparoscopy and thoracoscopy. MEASUREMENTS: We retrospectively reviewed the charts of 4 consecutive women with diaphragmatic endometriosis who underwent laparoscopy and thoracoscopy from June 2008 through September 2008. MAIN RESULTS: Four patients underwent a combination of laparoscopy for treatment of abdominopelvic endometriosis and thoracoscopy for treatment of diaphragmatic endometriosis. All patients had a history of chest pain. Three had a history of pelvic pain. Two had a history of catamenial hemothorax or pneumothorax. Two had been previously diagnosed with endometriosis, and three had a history of hormonal pharmacotherapy. All underwent laparoscopy and thoracoscopy without complications. All had uneventful recoveries. At nine-month follow-up, all patients were free of chest pain, and one patient had recurring pelvic pain. CONCLUSIONS: To the best of our knowledge, this constitutes the only reported series of patients with endometriosis who underwent a procedure systematically combining both laparoscopy and thoracoscopy for treatment of abdominopelvic and thoracic disease. It confirms that combined laparoscopic and thoracoscopic diagnosis and management of diaphragmatic endometriosis is reasonable. The inferior aspect of the diaphragm should be evaluated in all patients undergoing laparoscopy for endometriosis. Concomitant thoracoscopy should be considered for all patients with history of catamenial hemopneumothorax, cyclic chest or shoulder pain, or cyclic dyspnea. The aim of treatment should be to remove endometriotic lesions, to provide symptomatic relief, and to avoid recurrence. The use of these minimally invasive techniques may reduce the need for laparotomy or thoracotomy in affected patients.

J Minim Invasive Gynecol. 2009 Sep-Oct;16(5):540-50.

Endometriosis and mechanisms of pelvic pain.

Howard FM.

Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, USA. fred_howard@urmc.rochester.edu

Endometriosis remains an enigmatic disorder in that the cause, the natural history, and the precise mechanisms by which it causes pain are not completely understood. The pain symptoms most commonly attributed to endometriosis are dysmenorrhea, dyspareunia, and chronic pelvic pain. Pain may be due to nociceptive, inflammatory, or neuropathic mechanisms, and there is evidence that all 3 of these mechanisms are relevant to endometriosis-associated pelvic pain. It is proposed that the clinically observed inconsistencies of the relationships of endometriosis severity and the presence or severity of pain are likely due to variable roles of different pain mechanisms in endometriosis. A better understanding of the roles of nociceptive, inflammatory, and neuropathic pain in endometriosis is likely to improve the treatment of women with endometriosis-associated pelvic pain.

J Minim Invasive Gynecol. 2009 Sep-Oct;16(5):522-4.

Images in endoscopy. Laparoscopic excision of bilateral functioning noncommunicating and rudimentary uterine horns in a patient with Mayer-Rokitansky-Küster-Hauser syndrome and pelvic endometriosis.

Parkar RB, Kamau WJ.

Obstetrics and Gynecology, The Aga Khan University Hospital, Nairobi, Kenya. rafsan@africaonline.co.ke

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