Eur J Contracept Reprod Health Care. 2008 Sep;13(3):222-30.

Contraceptive applications of progesterone receptor modulators.

Chabbert-Buffet N, Ouzounian S, Kairis AP, Bouchard P.

Obstetrics and Gynaecology Unit, Hopital Tenon AP-HP, Paris, France. nathalie.chabbert-buffet@tnn.aphp.fr

Currently developed progesterone receptor modulators (PRMs) are steroid-derived compounds with mild or potent antiprogestin activity. PRMs may exert a contraceptive activity by different mechanisms such as blockade of ovulation and endometrial desynchronization. Their potential clinical applications are manifold and are very promising in major public health areas, including emergency contraception, long term oestrogen-free contraception (administered alone, or in association with a progestin-only pill to improve bleeding patterns), endometriosis and myoma treatment. The mechanisms of their anti-ovulatory effects and of the endometrial modifications elicited during long term PRM treatment are still not fully elucidated. In future clinical applications, PRMs will be administered orally, via intrauterine systems or vaginal rings.

Ginekol Pol. 2008 Jul;79(7):499-503.

[Dysmenorrhea in pediatric and adolescent gynaecology]

[Article in Polish]

Drosdzol A, Skrzypulec V.

Katedra Zdrowia Kobiety, Slaski Uniwersytet Medyczny w Katowicach. cor111@poczta.onet.pl

Dysmenorrhea is the most common problem in pediatric and adolescent gynaecology and it reaches approximately 20-90% of adolescents and young adult females. Dysmenorrhea in adolescent girls is usually primary and is associated with normal ovulatory cycles and with no pelvic pathology. Secondary dysmenorrhea, associated with some pelvic pathology, constitutes approximately 10% of the cases and its most frequent reasons are: endometriosis, pelvic inflammatory disease, congenital mullerian anomalies and ovarian cysts. Prostaglandins and leukotriens play a significant role in etiopathogenesis of the primary dysmenorrhea. The therapy of the primary dysmenorrheal in adolescent girls involves: nonsteroidal anti-inflammatory drugs for at least 3 months, combined with oral contraceptives for at least 3-6 menstrual cycles, as well as dietary supplementation, other alternative therapies (vitamins, herbal remedies, acupuncture, TENS) and surgical treatment Secondary causes of dysmenorrhea should be considered in adolescents with dysmenorrhea who do not respond to the treatment. The role of the pediatric and adolescent gynaecologist is to diagnose the reason of symptoms, educate the patient, review effective treatment options as well as to restore normal daily functioning.

Mol Endocrinol. 2008 Nov;22(11):2557-62. Epub 2008 Sep 25.

Gene expression profile for ectopic versus eutopic endometrium provides new insights into endometriosis oncogenic potential.

Borghese B, Mondon F, Noël JC, Fayt I, Mignot TM, Vaiman D, Chapron C.

Institut Cochin, Université Paris Descartes, Centre National de la Recherche Scientifique (Unité Mixte de Recherche 8104), Paris, France. bruno.borghese@inserm.fr

Endometriosis is a common gynecological disorder characterized by pain and infertility, where the lesions disseminate everywhere in the body with a preference for the pelvis. In that, it could be regarded as a benign metastatic disease, because its issue is not fatal. However, the molecular bases of this intriguing clinical condition are not well known. The objective of this study is to characterize the transcriptome differences between eutopic vs. ectopic endometrium with a special interest in pathways involved in cancerogenesis. We performed two hybridizations in technical replicate on highly specific long oligonucleotides microarrays (NimbleGen), with cDNA prepared from six-patients pools, where the same patient provided both eutopic and ectopic endometrium (endometriomas). To confirm the expression microarrays data, quantitative RT-PCR validation was performed on 12 individuals for 20 genes. Over 8000 transcripts were significantly modified (more than twice) in the lesions corresponding to 5600 down- or up-regulated genes. These were clustered through DAVID Bioinformatics Resources into 55 functional groups. The data are presented in a detailed and visual way on 24 Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways implemented with induction ratios for each differentially expressed gene. An outstanding control of the cell cycle and a very specific modulation of the HOX genes were observed and provide some new evidence on why endometriosis only very rarely degenerates into cancer. The study constitutes a noteworthy update of gene profiling in endometriosis, by delivering the most complete and reliable list of dysregulated genes to date.

Biol Reprod. 2009 Jan;80(1):105-14. Epub 2008 Sep 24.

Steroidogenic enzyme and key decidualization marker dysregulation in endometrial stromal cells from women with versus without endometriosis.

Aghajanova L, Hamilton A, Kwintkiewicz J, Vo KC, Giudice LC.

Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California 94143, USA.

Identification of mechanisms underlying endometriosis pathogenesis will facilitate understanding and treatment of infertility and pain associated with this disorder. Herein, we investigated the expression of steroidogenic pathway enzymes and key decidualization biomarkers in endometrial tissue and in eutopic endometrial stromal fibroblasts (hESFs) from women with vs. those without endometriosis, and subsequently treated in vitro with 8-bromo-cAMP (8-Br-cAMP) or progesterone (P4). Real-time quantitative PCR, immunohistochemistry, ELISA, and radiometric aromatase activity assay were used. The results demonstrate significantly increased (14.5-fold; P=0.037) expression of aromatase in eutopic endometrium of women with disease. In 8-Br-cAMP-treated hESF from eutopic endometrium of women with endometriosis, the balance in estradiol (E2) and P4 biosynthetic and metabolizing enzymes is disturbed (decreased HSD3B1 and HSD17B2, and increased HSD17B1 and aromatase), with the equilibrium being shifted towards an E2-enriched milieu. However, hESF from the same group of women treated with P4 did not demonstrate such responsiveness. Lower expression of IGFBP1 and prolactin mRNA and protein was observed in hESF from women with vs. those without endometriosis in response to 8-Br-cAMP, but not P4, suggesting a blunted response of these decidual biomarkers to activation of the PKA pathway in eutopic endometrium in women with disease. The dichotomy of 8-Br-cAMP regulation of select steroidogenic enzymes leading to an enriched E2 milieu within the endometrium and a blunted response of decidual biomarkers to this decidualizing agent of hESF from women with endometriosis suggests resistance to full decidualization of the stromal fibroblasts and mechanisms underlying implantation failure and the pathophysiology of this disorder.

J Reprod Immunol. 2008 Oct;79(1):111-7. Epub 2008 Sep 23.

Association of leptin with inflammatory cytokines and lymphocyte subpopulations in peritoneal fluid of patients with endometriosis.

Milewski Ł, Barcz E, Dziunycz P, Radomski D, Kamiński P, Roszkowski PI, Korczak-Kowalska G, Malejczyk J.

Department of Histology and Embryology, Centre of Biostructure Research, Medical University of Warsaw, Chałubińskiego 5, PL-02004 Warsaw, Poland.

INTRODUCTION: Endometriosis is a common, complex and chronic disease related to ectopic implantation and growth of endometrial tissue that may manifest by pelvic inflammatory reactions, chronic pelvic pain and subfertility. Endometriosis may be associated with increased peritoneal fluid leptin levels. Leptin is known to exert immunomodulatory effects; however, an association between leptin and inflammatory reactions in endometriosis has not been documented. Therefore, the aim of this study was to investigate a relationship between leptin concentrations in peritoneal fluid and the levels of peritoneal fluid inflammatory cytokines and mononuclear leukocyte subpopulations. MATERIALS AND METHODS: Peritoneal fluid was aspirated by laparoscopy from 46 women in whom endometriosis had been confirmed by clinical and histopathological examinations and from 10 control women qualified for ART in whom pelvic pathology has been excluded. Concentrations of leptin and inflammatory cytokines (IL-1beta, IL-6, IFN-gamma and TNF) in peritoneal fluid were evaluated by specific ELISAs. Percentage of peritoneal leukocyte subpopulations (CD3+, CD4+, CD8+ and CD14+) was analyzed by FACS using specific monoclonal antibodies. RESULTS: Leptin concentrations in peritoneal fluid correlated negatively with concentrations of IL-1beta and IFN-gamma (r(s)=-0.38, p=0.01 and r(s)=-0.31, p=0.03, respectively) and correlated positively with the percentage of CD3+ pan-T cells (r(s)=0.69, p=0.009) and CD4+ T helper cells (r(s)=0.74, p=0.036). CONCLUSIONS: Increased leptin levels in peritoneal fluid from endometriosis patients may affect local inflammatory/immune reactions, especially infiltration of CD4+ T helper cells. Thus, leptin may play an important role in the immunopathogenesis of endometriosis.

Saudi Med J. 2008 Sep;29(9):1340-1.

An incidental coexistence of Mayer-Rokitansky-Kuster-Hauser syndrome with pelvic ectopic kidney and perirenal endometrioma.

Balci O, Karatayli R, Capar M.

Department of Obstetrics and Gynecology, Meram Medicine Faculty, Selcuk University, Akyokus, 42080 Konya, Turkey. drobalci@yahoo.com

In this case report, a Mayer-Rokitansky-Kuster-Hauser syndrome with pelvic ectopic kidney and a perirenal cyst with endometrial tissue inside is demonstrated. A 17 year old patient admitted with primary amenorrhea. Pubertal stages were completed. In pelvic ultrasonography; uterus could not be detected, a 6 x 11 cm sized cystic lesion was seen on the right adnexal area. A centrally located 5.5 x 9 cm sized ectopic pelvic kidney was detected. Hormones and tumor markers were normal. Laparoscopy was planned. In the laparoscopic observation, uterus and both tubes could not be detected, ovaries were normal. There was a 6 x 7 cm sized cyst located in the retroperitoneal area, the origin of the cyst could not be identified. Laparatomy was considered, retroperitoneal space was entered, an 8 x 11 cm sized smooth contoured perirenal cyst adjacent to the pelvic kidney was detected. Cyst was extirpated. The pathology result was reported to include endometrial tissue and hemorrhage inside.

Saudi Med J. 2008 Sep;29(9):1315-8.

Comparison of hysterosalpingography and laparoscopy in the evaluation of infertile women.

Sakar MN, Gul T, Atay AE, Celik Y.

Department of Obstetrics and Gynecology, Ozel Veni Vidi Hospital, Faculty of Medicine, Dicle University, Diyarbakir, Turkey. nafisakar@dicle.edu.tr

OBJECTIVE: To compare tuboperitoneal factors of infertile women by hysterosalpingography (HSG) and laparoscopy. METHODS: In this cohort study, 82 infertile cases were evaluated retrospectively by laparoscopy, 3 months subsequent to HSG in the Department of Gynecology and Obstetrics, Medical School of Dicle University, Diyarbakir, Turkey, between March 2004 and April 2006. The findings of HSG and laparoscopy were compared. RESULTS: Out of the 82 infertile women, pathological findings were observed in 45.1% by HSG, and 54.9% had no pathological finding. On laparoscopic evaluation, however, pathological findings were observed in 65.85%, and 34.15% had no pathological findings. The pathological findings were detected by laparoscopy in 20 of the 45(44.4%) patients who had no pathological findings by HSG, and no pathological findings were detected by laparoscopy in 3 of the 37 (8.1%) patients who had pathological findings by HSG. Laparoscopy revealed no pathological findings in 6 of the 35 patients who had tubal pathology by HSG. The sensitivity of HSG was 63%, specificity was 89.3%, and the positive predictive value was 92%, with a 55% predictive value, and the accuracy ratio was 72%. CONCLUSION: Laparoscopy is a superior method for the research of tubal and pelvic pathologies in the evaluation of infertility. However, HSG is a more economical and elementary method suitable for evaluation of endometrial and tubal pathologies, and laparoscopy is an appropriate method for examining the external part of tubae, fimbriae, the relation of tuba and ovary, endometriosis, adhesions, tuberculosis, and other pathologies. Therefore, these 2 methods are not alternative, but complementary.

J Ultrasound Med. 2008 Oct;27(10):1479-83.

Comment in:

J Ultrasound Med. 2009 Mar;28(3):408-9; author reply 409-10.

J Ultrasound Med. 2009 Mar;28(3):410-1.

Sonorectovaginography: a new sonographic technique for imaging of the posterior compartment of the pelvis.

Bignardi T, Condous G.

Nepean Centre for Perinatal Care, Nepean Clinical School, University of Sydney, Nepean Hospital, Penrith, Sydney, NSW 2750, Australia. tommaso.bignardi@alice.it

OBJECTIVE: We describe the use of a new sonographic technique for imaging of the posterior compartment of the pelvis: sonorectovaginography. METHODS: Sonorectovaginography uses instillation of fluids (saline solution and ultrasound gel) in the vagina, pouch of Douglas, and rectum for the purpose of creating acoustic interfaces between the vagina, cervix, rectum, and pouch of Douglas. We performed sonorectovaginography in a woman with chronic pelvic pain during laparoscopy. Urinary catheters were introduced into the rectum and vagina. Sterile saline solution was introduced into the abdominal cavity through a laparoscopic trocar and in the rectum via a rectal catheter. The transvaginal probe was then inserted, and sterile ultrasound gel was introduced into the vagina through the vaginal catheter under sonographic guidance. RESULTS: Sonorectovaginography has helped us create acoustic interfaces and enhanced simultaneous visualization of the vaginal walls, posterior vaginal fornix, retrocervical area, rectovaginal septum, rectal wall, and pouch of Douglas. CONCLUSIONS: Imaging of the posterior compartment of the pelvis is of paramount importance for identification of potentially difficult endometriosis cases, such as those complicated by obliteration of the pouch of Douglas or infiltration of the retrocervical area, rectovaginal septum, or vaginal or rectal wall. Sonorectovaginography may prove helpful in evaluating this compartment of the pelvis in women with suspected deep endometriosis. Its reproducibility, tolerability, and accuracy, however, need to be validated prospectively, and normative data for the rectovaginal septum also need to be established.

Expert Opin Pharmacother. 2008 Oct;9(15):2661-72.

Dysmenorrhea in adolescents and young adults: from pathophysiology to pharmacological treatments and management strategies.

Harel Z.

Warren Alpert Medical School of Brown University, Hasbro Children’s Hospital/Rhode Island Hospital, Division of Adolescent Medicine, Department of Pediatrics, 593 Eddy Street, Providence, RI 02903, USA. Zharel@Lifespan.org

BACKGROUND: Dysmenorrhea is the most common gynecologic complaint among adolescent and young adult females. Dysmenorrhea is usually primary and is associated with normal ovulatory cycles and with no pelvic pathology. In approximately 10% of females with severe dysmenorrhea symptoms, pelvic abnormalities such as endometriosis or uterine anomalies may be found. OBJECTIVE: To review the current knowledge regarding the pathophysiology of dysmenorrhea, as well as review pharmacological treatments and strategies for management of dysmenorrhea in adolescent and young adult females. METHODS: Review of original articles on dysmenorrhea that have been published in the medical literature. RESULTS/CONCLUSIONS: Potent prostaglandins and potent leukotrienes play an important role in generating primary dysmenorrhea symptoms. Non-steroidal anti-inflammatory drugs (NSAIDs) are the most common pharmacologic treatment for dysmenorrhea. A loading dose of NSAIDs (typically twice the regular dose) should be used as initial treatment for dysmenorrhea, followed by a regular dose until symptoms abate. Adolescents and young adults with symptoms that do not respond to treatment with NSAIDs for three menstrual periods should be offered hormonal treatment such as combined estrogen/progestin oral contraceptive pills (OCPs) for three menstrual cycles. If dysmenorrhea does not improve within 6 months of treatment with NSAID and OCPs, a laparoscopy is indicated to look for endometriosis. The goal of pharmacological treatment for endometriosis is to block its abnormal positive feedback loop. The abnormal loop consists of high local levels of estrogen in the lesions, which induce transcription of COX-2 and synthesis of prostaglandin E(2.) This results in further expression and activity of aromatase and a further increase in estrogen.

Surg Technol Int. 2008;17:181-6.

Use of circular stapler for laparoscopic excision of rectosigmoid anterior wall endometriosis.

Pereira RM, Zanatta A, Reich H, Bianchi PH, Fettback PB, Motta EL, Serafini PC.

Obstetrics and Gynecology Department, Londrina State University, Londrina, Paraná, Brazil, Pelvic Surgery Department, Huntington Reproductive Medicine Centre, São Paulo, Brazil.

The objective of this study was to assess the feasibility and safety of laparoscopic rectosigmoid anterior wall discoid resection for endometriosis using the circular stapler. A retrospective analysis was conducted of nine consecutive patients undergoing laparoscopic radical excision of pelvic endometriosis, including bowel anterior wall discoid excision, at the Fertility and Pelvic Surgery Clinic and private hospitals in São Paulo, Brazil. The selected intervention was a radical laparoscopic endometriosis resection, including rectosigmoid anterior wall excision with the circular stapler. For certain types of bowel endometriosis, the anterior wall discoid stapler excision proved a suitable option that diminishes the chances of serious complications such as bowel fistula or anastomosis dehiscence.

Stress. 2008;11(5):390-7.

Salivary cortisol concentrations, stress and quality of life in women with endometriosis and chronic pelvic pain.

Petrelluzzi KF, Garcia MC, Petta CA, Grassi-Kassisse DM, Spadari-Bratfisch RC.

Laboratory for the Study of Stress, Department of Physiology and Biophysics, Institute of Biology, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil.

The objective of this study was to evaluate the perceived stress index, quality of life, and hypothalamus-pituitary-adrenal axis activity in women with endometriosis and chronic pelvic pain. For the study, 93 women with endometriosis and 82 healthy women volunteered. The visual analogue scale (VAS) (0=no pain; 10=severe pain) was used to determine pain intensity; the perceived stress questionnaire (PSQ) defined stress index, and the health-related quality-of-life (HRQOL)-SF-36 questionnaire was used to evaluate quality of life. Salivary cortisol was measured at 0800, 1600, and 2000 h and the awakening cortisol response was assessed to evaluate the hypothalamus-pituitary-adrenal axis activity. The results show that women with endometriosis and chronic pelvic pain of moderate intensity (4.1+/-0.58, mean+/-SEM) have higher levels of perceived stress (0.55+/-0.01 versus 0.42+/-0.01, p<0.05), a poorer quality of life expressed as lower scores for all items of the inventory and hypocortisolism. Lower levels of salivary cortisol were observed in all three samples collected, as well as in the awakening cortisol response, for women with endometriosis (0.19+/-0.09 microg/dl) when compared with controls (0.78+/-0.08 microg/dl, p<0.05 l), and it was independent of pain intensity and Mental health (MH) scores in SF-36. We concluded that women with endometriosis and chronic pelvic pain show low concentrations of salivary cortisol and a high level of perceived stress, associated with a poor quality of life. Whether the hypocortisolism was an adaptive response to the aversive symptoms of the disorder or a feature related to the etiology of endometriosis remains to be elucidated.

Ginecol Obstet Mex. 2008 Sep;76(9):549-57.

[Endometriosis: physiopathology and investigation lines (part two)]

[Article in Spanish]

Ayala Yánez R, Mota González M.

Departamento de endoscopia ginecológica, Instituto Nacional de Perinatología, México, DF.

Sampson’s menstrual reflux theory (1927) is widely accepted as an explanation of endometriosis physiopathology, it proposes five basic necessary processes to its development: adhesion, invasion, recruitment, angiogenesis and proliferation. Several factors and physiologic processes are necessary for the survival and growth of endometrial tissue. Clinical manifestations of these disease are: dysmenorrhoea, dyspareunia, and peritoneal adhesions, that with other findings reveal an inflammatory process that requires cytokines, macrophages, NK cells, lymphocytes and prostaglandins whose qualitative functions may be compromised or may contribute to the peripheral generation of estrogens. Angiogenesis benefits the development of these endometrial tissue foci and probably stimulates several vascular growth factors, and sexual steroids. Endocrine factors are capital for this entity, as is demonstrated by the presence of estrogen receptors in macrophages, fibroblasts and endometrium among others, as well as the clinical symptoms control trough the blockage of the hypothalamus-pituitary-ovary axis. Studies on the genetic and antioxidant factors have revealed key points that may be helpful in determining a proper diagnosis and treatment for endometriosis.

Ginecol Obstet Mex. 2008 Apr;76(4):228-32.

[Endometrial tissue in myometrium vessels. Two cases report and literature review]

[Article in Spanish]

Hernández Monge A, Estrada Hernández R, Estrada Moscoso I, Pacheco Pineda R, Márquez Iribe P, Díaz Flores O.

Hospital General Dr. Manuel Gea González, SSA, México, DF. alejandrohernandezmonge@yahoo.com.mx

Endometrial tissue in the myometrium vessels space, whit no relation to menstrual period, is a rarely reported event. It is unknown if it is part of the natural history of ectopic localization of endometrial tissue or it is related to more or less aggressive behavior of endometriosis. This paper reports two cases: a 35- and 51-year-old women. The first one made suspect a clear cells adenocarcinoma undiagnosed before hysterectomy, because there were no endometrial glands in the myometrium vessels space, but only nest of stromal cells isolated, simulating thrombus of an invasive neoplasm. Since a wrong diagnosis affects the integral treatment of patients, differential diagnosis must be established in order to increase certainty.

Ginecol Obstet Mex. 2008 Feb;76(2):125-30.

[Diagnostic difficulty of abdominal wall endometrioma: clinical case and literature review]

[Article in Spanish]

Martínez DG, Romano RC, Sánchez AW, Horcasitas LM.

Hospital Angeles Lomas. Vialidad de la Barranca s/n, C410, Valle de las Palmas, CP 52763, Huixquilucan, Estado de Mexico, Mexico. denzilgarteiz@yahoo.com

Abdominal wall endometrioma is a rare clinical condition with which the general surgeon is faced and usually presents a diagnostic challenge due to the similar signs and symptoms that this illness shares with other tumors of the abdominal wall. A clinical case which exemplifies this diagnostic challenge is presented, and a review is made about the physiopathology, diagnosis and treatment of abdominal wall endometriomas, emphasizing on the different diagnoses with which it can be confused.

Curr Opin Obstet Gynecol. 2008 Oct;20(5):464-9.

Intrauterine devices and adolescents.

Gold MA, Johnson LM.

Division of Adolescent Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, PA 15213, USA. magold@pitt.edu

PURPOSE OF REVIEW: The purpose of this review is to inform the reader of new information published on intrauterine devices (IUDs) and adolescents. RECENT FINDINGS: There are few studies on the use of IUDs in adolescents. The article reviews topics related to IUD use such as adolescents’ knowledge of and attitudes toward IUDs, mechanism of action of copper-releasing and levonorgestrel-releasing IUDs, benefits of using IUDs with adolescents, safety, side effects, as well as noncontraceptive benefits such as management of menstrual disorders and endometriosis using IUDs. SUMMARY: IUDs are a safe and effective long-term contraceptive method with no increase in risk of pelvic inflammatory disease, tubal infertility or ectopic pregnancies. IUDs are underutilized in the United States, especially by adolescents. Because adolescents contribute disproportionately to the epidemic of unintended pregnancy, IUDs should be considered as a first-line contraceptive choice regardless of parity. The levonorgestrel-releasing intrauterine system (LNG IUS) is a particularly good choice for adolescents because of associated noncontraceptive benefits such as decreased menstrual bleeding, dysmenorrhea and pain associated with endometriosis. There is a clear need for further studies in the use of the IUD among adolescents.

J Pediatr Adolesc Gynecol. 2008 Oct;21(5):247-57.

Japanese-style acupuncture for endometriosis-related pelvic pain in adolescents and young women: results of a randomized sham-controlled trial.

Wayne PM, Kerr CE, Schnyer RN, Legedza AT, Savetsky-German J, Shields MH, Buring JE, Davis RB, Conboy LA, Highfield E, Parton B, Thomas P, Laufer MR.

Harvard Medical School, Osher Research Center, Boston, Massachusetts 02215, USA. peter_wayne@hms.harvard.edu

STUDY OBJECTIVE: To assess feasibility, and collect preliminary data for a subsequent randomized, sham-controlled trial to evaluate Japanese-style acupuncture for reducing chronic pelvic pain and improving health-related quality of life (HRQOL) in adolescents with endometriosis. DESIGN: Randomized, sham-controlled trial. SETTINGS: Tertiary-referral hospital. PARTICIPANTS: Eighteen young women (13-22y) with laparoscopically-diagnosed endometriosis-related chronic pelvic pain. INTERVENTIONS: A Japanese style of acupuncture and a sham acupuncture control. Sixteen treatments were administered over 8 weeks. MAIN OUTCOME MEASURES: Protocol feasibility, recruitment numbers, pain not associated with menses or intercourse, and multiple HRQOL instruments including Endometriosis Health Profile, Pediatric Quality of Life, Perceived Stress, and Activity Limitation. RESULTS: Fourteen participants (out of 18 randomized) completed the study per protocol. Participants in the active acupuncture group (n = 9) experienced an average 4.8 (SD = 2.4) point reduction on a 11 point scale (62%) in pain after 4 weeks, which differed significantly from the control group’s (n = 5) average reduction of 1.4 (SD = 2.1) points (P = 0.004). Reduction in pain in the active group persisted through a 6-month assessment; however, after 4 weeks, differences between the active and control group decreased and were not statistically significant. All HRQOL measures indicated greater improvements in the active acupuncture group compared to the control; however, the majority of these trends were not statistically significant. No serious adverse events were reported. CONCLUSION: Preliminary estimates indicate that Japanese-style acupuncture may be an effective, safe, and well-tolerated adjunct therapy for endometriosis-related pelvic pain in adolescents. A more definitive trial evaluating Japanese-style acupuncture in this population is both feasible and warranted.

South Med J. 2008 Oct;101(10):1043-5.

Comment in:

South Med J. 2008 Oct;101(10):989-90.

Catamenial pneumothorax with umbilical and diaphragmatic endometriosis: a case report and review of the literature.

Arunthari V, Sevin BU, Krishna M, Johnson MM.

Division of Pulmonary Medicine, Mayo Clinic Jacksonville, Jacksonville, FL 32224, USA. arunthari.vichaya@mayo.edu

A 44-year-old female presented with a history of recurrent right-sided pneumothoraces, uterine fibroids, and a palpable lump in her navel. Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) and resection of the umbilical nodule was performed. Intraoperative inspection of the right hemidiaphragm revealed adherent brownish-blue nodules without any associated diaphragmatic defects and a similar-appearing nodule at the umbilicus. She had no symptoms of pelvic endometriosis, nor did surgical exploration reveal any. Her postoperative course was uneventful and she denied recurrent pneumothorax at 12-month followup. Recurrent pneumothoraces in women of a reproductive age should raise the suspicion of thoracic endometriosis. Failure to establish the diagnosis prevents appropriate curative interventions.

South Med J. 2008 Oct;101(10):989-90.

Comment on:

South Med J. 2008 Oct;101(10):1043-5.

Thoracic endometriosis syndrome: not so rare after all?

Parker CM.

 

Gut. 2008 Oct;57(10):1353, 1479.

A rare diagnosis of right upper quadrant abdominal pain.

Chung CS, Wang HP, Fang YJ, Hu RH, Hsiao JK, Chen CH.

Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, 7, Chung-Shan South Road, Taipei, Taiwan, 100.

Zhonghua Fu Chan Ke Za Zhi. 2008 Mar;43(3):185-8.

[Associations of metabolism of lipid, calcium and phosphate in endometriosis]

[Article in Chinese]

Lu BC, Zhang XM.

Department of Gynecology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China.

OBJECTIVE: To investigate the metabolism of lipid, calcium and phosphorus in women with endometriosis. METHODS: Clinical data of 223 patients with endometriosis and 200 patients without endometriosis were retrospectively analyzed. Electrochemiluminoimmunoassay was used to detect the levels of serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone (T), estradiol (E2) and progesterone (P), and photoelectric colorimetry was used to determine the concentrations of serum triglyceride (TG), total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL), calcium and phosphorus in the patients with and without endometriosis. RESULTS: The levels of serum P were 2.0 nmol/L and 1.8 nmol/L in endometriosis patients with age < or = 35 years old (case group A) and > 35 years old (case group B), and 1.6 nmol/L and 1.2 nmol/L in patients without endometriosis at age < or = 35 years old (control group A) and > 35 years old (control group B), respectively. A significant difference was found between case group A and control group A, and between case group B and control group B. The levels of serum LH was significantly higher in case group B (7.2 U/L) than that in control group B (6.1 U/L), however, there was no significant difference between case group A (7.0 U/L) and control group A (6.5 U/L). Also no significant difference in serum FSH, T and E2 levels was found between case group A (respectively, 6.2 U/L, 1.1 nmol/L and 269 pmol/L) and control group A (respectively, 6.3 U/L, 1.1 nmol/L and 264 pmol/L), also between case group B (respectively, 6.6 U/L, 1.0 nmol/L and 345 pmol/L) and control group B (6.6 IU/L, 0.9 nmol/L and 279 pmol/L). The concentrations of serum TG in case group A and B (0.71 mmol/L and 0.72 mmol/L) were significantly lower than in control group A and B (0.92 mmol/L and 1.08 mmol/L), respectively. The concentrations of serum LDL in case group A and B [(2.2 +/- 0.5) mmol/L and (2.4 +/- 0.6) mmol/L]were also significantly lower than in control group A and B [(2.4 +/- 0.7) mmol/L and (2.62 +/- 0.63) mmol/L], respectively. However, the concentrations of serum HDL in case group A and B [(1.62 +/- 0.31) mmol/L and (1.53 +/- 0.32) mmol/L] were significantly higher than in control group A and B [(1.48 +/- 0.21) mmol/L and (1.37 +/- 0.22) mmol/L] , respectively. In addition, the concentrations of serum TC were not significantly different between case group A and control group A [(4.2 +/- 0.7) mmol/L and (4.29 +/- 0.71) mmol/L], and between case group B and control group B [(4.4 +/- 0.8) mmol/L and (4.5 +/- 0.7) mmol/L]. The levels of serum phosphorus in case group A and B [(1.01 +/- 0.22) mmol/L and (0.89 +/- 0.18 mmol/L] were significantly lower than in control group A and B [1.23 +/- 0.24 mmol/L and (1.10 +/- 0.13) mmol/L], respectively. But the levels of serum calcium had no significant difference between case group A and control group A [(2.33 +/- 0.23) mmol/L and (2.41 +/- 0.12) mmol/L], and between case group B and control group B [(2.40 +/- 0.28) mmol/L and (2.42 +/- 0.20) mmol/L]. CONCLUSION: The abnormal metabolism of lipid and phosphorus, and the higher levels of serum P may playing a role in the pathogenesis of endometriosis.

N Engl J Med. 2008 Sep 11;359(11):1136-42.

Comment in:

N Engl J Med. 2008 Dec 25;359(26):2844; author reply 2844-5.

Gonadotropin-releasing hormone agonists for endometriosis.

Olive DL.

Wisconsin Fertility Institute, Middleton, WI 53562, USA. dlolive1@aol.com

Cir Esp. 2008 Sep;84(3):164.

[Endometriosis-induced rectal stenosis]

[Article in Spanish]

Alonso Gonçalves S, Pera Román M, Gil Egea MJ, Grande Posa L.

Unidad de Cirugía Colorrectal, Servicio de Cirugía General, Hospital del Mar, Barcelona, España.

Zhong Xi Yi Jie He Xue Bao. 2008 Sep;6(9):960-3.

[Effects of Quyu Jiedu Granule on expressions of tumor necrosis factor-alpha and interleukin-6 mRNAs in ovarian granulosa cells of endometriosis rats]

[Article in Chinese]

Li XL, Lian F, Liu YH.

Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province 250014, China.

OBJECTIVE: To observe the effects of Quyu Jiedu Granule, a compound traditional Chinese herbal medicine for removing blood stasis and expelling superficial evils, on the quality of oocytes and the expressions of tumor necrosis factor-alpha (TNF-alpha)and interleukin-6 (IL-6) mRNAs in ovarian granulosa cells of endometriosis (EM) rats. METHODS: Forty EM rats were randomly divided into two groups: experimental group and control group. There were 20 EM rats in each group. The uteri of another 20 SD rats were drawn in sham-operated group. The number and percentage of high quality oocytes and the levels of TNF-alpha and IL-6 mRNA expressions in the granulosa cells of EM rats were detected by using reverse transcription-polymerase chain reaction. RESULTS: The number and percentage of high quality oocytes in the experimental group were significantly higher than those in the control group (P<0.05), and the levels of TNF-alpha and IL-6 mRNAs in granulose cells in the experimental group were significantly lower than those in the control group (P<0.05). CONCLUSION: The increase of the TNF-alpha and IL-6 mRNA expressions in ovarian granulose cells of EM rats leads to the decrease of the oocyte quality. The mechanism of Quyu Jiedu Granule in improving the quality of oocytes may be related to the decrease of TNF-alpha and IL-6 mRNA expressions in ovarian granulosa cells.

Curr Med Chem. 2008;15(21):2099-107.

Endometriosis management: workflow on genomics and proteomics and future biomolecular pharmacotherapy.

Tinelli A, Martignago R, Vergara D, Leo G, Malvasi A, Tinelli R.

Department of Obstetrics and Gynecology, Vito Fazzi Hospital, Lecce, Italy. andreatinelli@gmail.com

BACKGROUND: Endometriosis is an estrogen-dependent disease, associated with pelvic pain and infertility, with still limited knowledge of the pathogenesis, pathophysiology of related infertility and evolution. OBJECTIVE: To investigate proteogenomic approaches and new trends of endometriosis treatment. METHODS: A literature search was carried out for all articles on endometriosis related to immune system, and to non-hormonal, antiangiogenic and experimental therapies. RESULTS/CONCLUSIONS: Classic endometriosis pharmacotherapy is represented by GnRH agonists, oral contraceptives and Type II progesterone receptor ligands. New proteomic and genomic technologies could help to clarify the aetiology of endometriosis and promise the rapid identification of a new generation of drugs with a specific molecular target, with the aim to ameliorate the patients’ quality of life.

Fertil Steril. 2008 Nov;90(5):2015.e17-9. Epub 2008 Sep 7.

Massive ascites as a presentation in a young woman with endometriosis: a case report.

Sait KH.

Department of Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia. khalidsait@yahoo.com

OBJECTIVE: To report a case of endometriosis associated with massive ascites and an elevated CA-125 level. DESIGN: Case report. SETTING: Tertiary care center. PATIENT(S): A 26-year-old woman presented with massive ascites and an increased CA-125 level suggestive of ovarian cancer. INTERVENTION(S): Ultrasonography, laparotomy, and bilateral ovarian cystectomy and reconstruction. Endometriosis was diagnosed postoperatively on the basis of histopathology. The patient received 6 months of treatment with a GnRH analogue. MAIN OUTCOME MEASURE(S): Ultrasound examination 6 months after surgery to evaluate for ascites or recurrent ovarian cysts. RESULT(S): Frozen sections obtained at laparotomy and ovarian cystectomy ruled out a malignancy. The final histologic report was compatible with a diagnosis of endometriosis. After 6 months of treatment with the GnRH analogue, the patient experienced a progressive reduction of the ascitic fluid and full remission after 2 years. CONCLUSION(S): Endometriosis associated with massive bloody ascites is an unusual occurrence. This report draws attention to this condition as a complication of endometriosis. For this reason, endometriosis should be included in the differential diagnosis of reproductive-age women presenting with an apparent ovarian malignancy.

Expert Opin Pharmacother. 2008 Oct;9(14):2473-85.

Selective progesterone receptor modulators 2: use in reproductive medicine.

Benagiano G, Bastianelli C, Farris M.

University ‘la Sapienza’, Postgraduate School of Gynaecology and Obstetrics, Policlinico Umberto I degrees , Viale Regina Margherita 245, 00161 Roma, Italy.

BACKGROUND: Synthetic compounds can bind to progesterone receptors and these progesterone receptor ligands exhibit a spectrum of activities ranging from pure antagonism to a mixture of agonism and antagonism. These substances have been classified as antiprogestins or as selective progesterone receptor modulators. OBJECTIVE: There are several hundred selective progesterone receptor modulators available, although only a dozen or so have been evaluated to any significant extent. The best-known selective progesterone receptor modulators are mifepristone (RU 486), asoprisnil (J 867), onapristone (ZK 98299), ulipristal (CDB 2914), Proellex() (CDB 4124), ORG 33628 and ORG 31710. Methods: A careful evaluation of existing major review papers and of recently published articles was carried out for the indications under review, focusing not only on mifepristone, but also on those other selective progesterone receptor modulators for which data are available. RESULTS/CONCLUSIONS: Outside pregnancy, selective progesterone receptor modulators are used or have been tested clinically for a number of indications in reproductive medicine: as oral contraceptives, alone or in combination with a progestin, to improve cycle control in users of progestin-only contraceptives, as emergency contraceptives, for the medical treatment of uterine fibroids, in cases of endometriosis and premenstrual syndrome and to improve ovarian stimulation prior to in vitro fertilisation. In the authors’ opinion, as of today, few applications outside pregnancy seem worthy of large-scale use: emergency contraception and long-term medical management of uterine fibroids and possibly of endometriosis.

Reprod Biol Endocrinol. 2008 Sep 7;6:40.

TLR3 and TLR4 expression in healthy and diseased human endometrium.

Allhorn S, Böing C, Koch AA, Kimmig R, Gashaw I.

Institute of Anatomy II, University of Duisburg-Essen, Essen, Germany.

BACKGROUND: Toll-like receptors (TLRs) play an essential role in the innate immune system by initiating and directing immune response to pathogens. TLRs are expressed in the human endometrium and their regulation might be crucial for the pathogenesis of endometrial diseases. METHODS: TLR3 and TLR4 expression was investigated during the menstrual cycle and in postmenopausal endometrium considering peritoneal endometriosis, hyperplasia, and endometrial adenocarcinoma specimens (grade 1 to 3). The expression studies applied quantitative RT-PCR and immunolabelling of both proteins. RESULTS: TLR3 and TLR4 proteins were mostly localised to the glandular and luminal epithelium. In addition, TLR4 was present on endometrial dendritic cells, monocytes and macrophages. TLR3 and TLR4 mRNA levels did not show significant changes during the menstrual cycle. In patients with peritoneal endometriosis, TLR3 and TLR4 mRNA expression decreased significantly in proliferative diseased endometrium compared to controls. Interestingly, ectopic endometriotic lesions showed a significant increase of TLR3 und TLR4 mRNA expression compared to corresponding eutopic tissues, indicating a local gain of TLR expression. Endometrial hyperplasia and adenocarcinoma revealed significantly reduced receptor levels when compared with postmenopausal controls. The lowest TLR expression levels were determined in poor differentiated carcinoma (grade 3). CONCLUSION: Our data suggest an involvement of TLR3 and TLR4 in endometrial diseases as demonstrated by altered expression levels in endometriosis and endometrial cancer.

J Minim Invasive Gynecol. 2008 Nov-Dec;15(6):663-6. Epub 2008 Sep 6.

Is there a role for use of levonorgestrel intrauterine system in women with chronic pelvic pain?

Anpalagan A, Condous G.

Early Pregnancy, Acute Gynecology and Advanced Endosurgery Unit, Nepean Center for Perinatal Care, Nepean Clinical School, University of Sydney, Nepean Hospital, NSW, Australia. anpalagana@bigpond.com

This review focuses on the available evidence for the use of levonorgestrel (LNG) intrauterine system (IUS) in women with chronic pelvic pain (CPP). We have searched MEDLINE, Pubmed, Embase, and the Cochrane electronic library with the keywords “chronic pelvic pain,” “endometriosis,” “Mirena IUS,” and “levonorgestrel IUS” from 1956 through April 2008. Review articles, randomized trials, prospective cohort studies, and retrospective studies were analyzed and the available evidence included in this review. Case reports were not included in the analysis. Laparoscopic surgery was shown to be useful in clarifying the underlying cause in women with CPP, with 70% having abnormal findings at laparoscopy. Endometriosis, particularly deep infiltrating endometriosis, is found in 40% to 60% of women with dysmenorrhea. Laparoscopic excision of endometriosis was shown to be associated with improvement of symptoms in 70% to 80% of women. Up to 36% need repeated surgery during a 5-year period after the primary procedure. The absolute reduction in recurrence of dysmenorrhea in women who also had the LNG IUS inserted at the time of surgery was 35% (95% CI 9%-61%). The LNG IUS was shown also to reduce the blood flow in the uterine artery and the subendometrial spiral arteries. This may explain the reduction in primary dysmenorrhea in women who have the LNG IUS inserted. Insertion of the LNG IUS at the time of primary laparoscopic surgery in women with CPP caused by endometriosis has the potential to reduce postoperative pain scores. This medical approach is also a promising alternative to repeated laparoscopic surgery especially in those women who have continuing symptoms after laparoscopic excision of endometriosis. This nonsurgical option could potentially reduce the rate of repeated laparoscopies in women with CPP and, in turn, reduce overall intervention rates. Although growing evidence exists that the LNG IUS can be useful in this group of women, large randomized controlled studies are needed to validate its benefits in day-to-day practice.

Zhongguo Zhen Jiu. 2008 Aug;28(8):579-81.

[Observation on therapeutic effect of acupuncture and moxibustion on disorders of myometrial gland]

[Article in Chinese]

Yan H, Huang XH, Deng GF.

Jinwan District Sanzao Hospital, Zhuhai City Guangdong Province, Zhuhai 519040, China.

OBJECTIVE: To explore the therapeutic effect of acupuncture on disorders of myometrial gland and the mechanism. METHODS: Sixty-six cases were randomly divided into an acupuncture group and a medication group, 33 cases in each group. The acupuncture group were treated with acupuncture at Zhongji (CV 3), Shuidao (ST 28), Tainshu (ST 25), Qugu (CV 2), Zigong (EX-CA 1) as main; the medication group were treated with oral administration of Danazol. Changes of estradiol (E2) level, hemoglobin (Hb) and blood platelet counter (BPC) were observed in the acupuncture group, and the therapeutic effects of the two group were compared. RESULTS: The total effective rate was 97.0% in the acupuncture group and 72.7% in the medication group, the former being better than the latter (P<0.05). After treatment, E2 level decreased and Hb and BPC increased in the acupuncture group. CONCLUSION: Acupuncture has obvious therapeutic effect, which is better than that of simple western medicine. Acupuncture can decrease E2 level.

Zhongguo Zhen Jiu. 2008 Aug;28(8):579-81.

[Observation on therapeutic effect of acupuncture and moxibustion on disorders of myometrial gland]

[Article in Chinese]

Yan H, Huang XH, Deng GF.

Jinwan District Sanzao Hospital, Zhuhai City Guangdong Province, Zhuhai 519040, China.

OBJECTIVE: To explore the therapeutic effect of acupuncture on disorders of myometrial gland and the mechanism. METHODS: Sixty-six cases were randomly divided into an acupuncture group and a medication group, 33 cases in each group. The acupuncture group were treated with acupuncture at Zhongji (CV 3), Shuidao (ST 28), Tainshu (ST 25), Qugu (CV 2), Zigong (EX-CA 1) as main; the medication group were treated with oral administration of Danazol. Changes of estradiol (E2) level, hemoglobin (Hb) and blood platelet counter (BPC) were observed in the acupuncture group, and the therapeutic effects of the two group were compared. RESULTS: The total effective rate was 97.0% in the acupuncture group and 72.7% in the medication group, the former being better than the latter (P<0.05). After treatment, E2 level decreased and Hb and BPC increased in the acupuncture group. CONCLUSION: Acupuncture has obvious therapeutic effect, which is better than that of simple western medicine. Acupuncture can decrease E2 level.

Ugeskr Laeger. 2008 Aug 11;170(33):2460.

[Triplet pregnancy following IVF treatment with a single embryo]

[Article in Danish]

Alsbjerg B, Humaidan PS.

Sygehus Viborg (Skive), Fertilitetsklinikken. alsbjerg@dadlnet.dk

We report a case in which a patient received IVF treatment due to massive pelvic endometriosis. The tubal patency and sperm parameters were normal. After e-SET (elective single embryo transfer) ultrasonography showed a triplet pregnancy with thick dividing membranes and lambda sign between all sacs. Two monozygotic and one dizygotic girl were delivered by Caesarean section at 28 weeks gestation. The couple had intercourse 2 days prior to the oocyte pick up (OPU) and the triplet pregnancy was attributed to a combination of assisted and spontaneous conception.

Clin Imaging. 2008 Sep-Oct;32(5):396-9.

Multidetector row helical computed tomography enteroclysis findings in ileal endometriosis.

Zouari-Zaoui L, Soyer P, Merlin A, Boudiaf M, Nemeth J, Rymer R.

Department of Abdominal Imaging, Hôpital Lariboisière-AP-HP and Université Paris 7, 2 rue Ambroise Paré, 75010 Paris, France.

Ileal endometriosis is a rare condition, which, most of the time, is found incidentally in women who have had abdominal or pelvic surgery. In general, ileal endometriosis is asymptomatic and is responsible for small bowel obstruction in only 0.5% of the cases. In addition, in most published cases, the diagnosis was established postoperatively. We report herein two cases of ileal endometriosis, which were responsible for small bowel occlusion. The diagnosis was considered preoperatively owing to the presence of a constellation of findings, including those obtained on multidetector row helical CT enteroclysis images. Multidetector row helical CT enteroclysis demonstrated dilated small bowel up to a stenosis due to circumferential parietal thickening in the distal ileum in one case and an ileal parietal solid nodule in the other one. Although multidetector row helical CT enteroclysis does not show specific findings, it may help to suggest the diagnosis of ileal endometriosis in the proper clinical setting.

Akush Ginekol (Sofiia). 2008;47(3):50-5.

[Endometriosis genitalis–clinical classification on the background of uncertain etiology and therapeutic anarchy]

[Article in Bulgarian]

Nalbanski A.

Clinical confusion and inappropriate management continues to surround endometriosis. It is poorly recognized that the disorder can exist in two different morphological forms that have different symptoms, signs and prognosis. Earlier classification systems have been useful for research but are of limited value in aiding day-to-day management. In the clinic, two discrete phenotypes can be defined by the presence or absence of palpable nodules in the deep pelvis. Patients with such nodules with or without associated ovarian endometrioma usually have severe symptoms with significant risks of bowel and urinary tract involvement. The predominant histological feature of these lesions is extensive fibromuscular hyperplasia (adenomyoma). These patients will often need extensive surgical intervention. Patients without such palpable lesions usually have the classic superficial subperitoneal lesions with endometrial-like glands and stroma on histological examination. This group often has less severe symptoms and has little risk of developing serious associated problems. These lesions may be helped by medications and/or simple ablative surgery. It is suggested that these collections of symptoms and signs or syndromes be named after the pioneers who first described the lesions. Cullen’s syndrome can be used to describe those patients with severe symptoms of endometriosis associated with palpable pelvic nodules. Sampson’s syndrome can describe those with similar symptoms associated with a structurally normal pelvis. This paper seeks to present evidence to suggest the reality of this ‘two forms of endometriosis’ concept, and the possibility of developing a simple clinically useful method of differentiating them.

Akush Ginekol (Sofiia). 2008;47(3):32-9.

[Laparoscopic findings in women with chronic pelvic pain]

[Article in Bulgarian]

Lukanova M, Miteva I, Gorgioski S, Popov I.

OBJECTIVE: To determine the frequency and analyze the findings during laparoscopy in women with chronic pelvic pain /CPP/. MATERIALS AND METHODS: The study was conducted in the period 01.03.2004-01.07.2007 in the Gynaecological clinic at the Department of Obstetrics and Gynaecology, MU-Pleven. Eighty-six women were consecutively admitted in the Clinic, presenting with pelvic pain with duration more than 6 months and who underwent laparoscopy in order to be diagnostically defined more accurately or operatively treated. They were classified according to their socio-demographic characteristics, reproductive history/fertility and parity/, presence of preceding operative interventions, and findings during laparoscopy. RESULTS AND DISCUSSION: The most frequent findings in women with CPP during laparoscopy were endometriosis /56,98%/ and adhaesion syndrome /39,53%/, and with a lower frequency-pelvic varicosis /17.44%/ and Allen-Masters syndrome /24,42%/. The most common localization of endometriotic foci was on ovaries/40,7%/and plica vesicouterina /18,6 %/, and of the varicose dilated veins-along vv.ovaricae and in the basis of the broad ligaments/resp. 89,96 and 60%/. CONCLUSION: Laparoscopy is an exceptionally valuable and useful method in diagnosing and differentiating the etiology of chronic pelvic pain symptoms, because of the frequent presence of more than one cause with pelvic localization for its appearance.

Akush Ginekol (Sofiia). 2008;47(3):20-9.

[Chronic pelvic pain and combined oral hormonal contraception]

[Article in Bulgarian]

Lukanova M, Popov I.

PURPOSE OF THE STUDY: To determine the frequency of usage of combined oral hormonal contraception/COHC/ and its efficiency in women with chronic pelvic pain/CPP/. MATERIALS AND METHODS: Three-hundred and seventy, consecutively admitted in the Clinic women with CPP, were included in the study. They were divided into 2 groups–group A/n = 80/–women that had used COHC, and group B/n = 290/–women that had not used COHC in order to cope with pain symptomatic. The patients from the both groups were compared according to their socio-demographic, menstrual and reproductive characteristics, type of disease, duration of CPP assessment of pain intensity and McGill pain indices, subjective rating of efficiency of the used COHC by the means of 5-rate scale in diseases, manifested with chronic pain symptomatic/leiomyoma /L/ endometriosis/E, pelvic congestion syndrome/PCS/, adhaesion syndrome/AS, Allen-Masters syndrome and other gynaecologic pathology/OGP/–chronic pelvic inflammatory disease/ CPID/, ovarian cysts /OC/, etc./. RESULTS AND DISCUSSION: Duration of CPP /in months/ was comparatively longer in group A /50,74 +/- 10,33/in comparison wit group B/41,38 +/- 5,97/. No significant difference was found in quantitative pain assessment, but in group A higher values of all pain indices/sensory, affective, total pain rating index/and of evaluative overall pain intensity of total pain experience were set, compared with those of group B. It was ascertained a bigger number of types of used medicines in group A/analgesics, spasmolytics, gestagenes and GnRH-agonists/. Efficiency of COHC was assessed by the patients in the range “good-/basically/very good-excellent”, and that was well demonstrated by women with L, E, AS and OGP/CPID, etc./. CONCLUSION: COHC was administered to patients with more heavily demonstrated chronic pelvic pain symptomatic, that required combination of more than two medicines in order to obtain a better therapeutic effect. Diseases, manifesting with CPP like E, L and OGP/CPID, OC, AS, etc/are of great priority in treatment with COHC.

Semin Reprod Med. 2008 Jul;26(4):356-68.

Disorders of adhesions or adhesion-related disorder: monolithic entities or part of something bigger–CAPPS?

Wiseman DM.

Synechion, Inc, and International Adhesions Society, Dallas, Texas 75248, USA. david.wiseman@adhesions.org

The purpose of this article is to review progress in the field of abdominopelvic adhesions and the validity of its two underlying assumptions: (1) The formation of adhesions results in infertility, bowel obstruction, or other complications. Reducing or avoiding adhesions will curb these sequelae. (2) “Adhesions” is a monolithic entity to be tackled without regard to any other condition. Evidence is discussed to validate the first assumption. We reviewed progress in the field by examining hospital data. We found a growing trend in the number and cost of discharges for just two adhesion-related diagnoses, and the low usage of adhesion barriers appears in at most 5% of appropriate procedures. Data from an Internet-based survey suggested that the problem may be partly due to ignorance among patients and physicians about adhesions and their prevention. Two other surveys of patients visiting the adhesions.org Web site defined more fully adhesion-related disorder (ARD). The first survey ( N = 466) described a patient with chronic pain, gastrointestinal disturbances, an average of nine bowel obstructions, and an inability to work or maintain family or social relationships. The second survey (687 U.S. women) found a high (co-) prevalence of abdominal or pelvic adhesions (85%), chronic abdominal or pelvic pain (69%), irritable bowel syndrome (55%), recurrent bowel obstruction (44%), endometriosis (40%), and interstitial cystitis (29%). This pattern suggests that although “adhesions” may start out as a monolithic entity, an adhesions patient may develop related conditions (ARD) until they merge into an independent entity where they are practically indistinguishable from patients with multiple symptoms originating from other abdominopelvic conditions such as pelvic or bladder pain. Rather than use terms that constrain the required multidisciplinary, biopsychosocial approach to these patients by the paradigms of the specialty related to the patient’s initial symptom set, the term complex abdominopelvic and pain syndrome (CAPPS) is proposed. It is essential to understand not only the pathogenesis of the “initiating” conditions but also how they progress to CAPPS. In our ARD sample, not only was the frequency of women with hysterectomies (56%) higher than expected (21 to 33%), but also the rates of the “initiating” conditions was 40 to 400% higher in patients with hysterectomies than in those without. This may represent increased surgical trauma or the loss of protection against oxidative stress. Related was the higher frequency of ARD patients reporting hemochromatosis (HC; 5%) than expected (~0.5%) and the higher rates (20 to 700%) of initiating conditions in patients with HC than in those without HC. Together with findings related to the toxicity of Intergel, these findings raise the possibility that heterozygotes for genes regulating oxidative stress are at greater risk of developing surgical complications as well as more severe and progressive conditions such as CAPPS.

Semin Reprod Med. 2008 Jul;26(4):298-312.

TGF-beta system: the principal profibrotic mediator of peritoneal adhesion formation.

Chegini N.

Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Institute for Wound Research, University of Florida, Gainesville, Florida 32610, USA. cheginin@obgyn.ufl.edu

Whether induced by infection, inflammation, ischemia, and/or surgical injury, peritoneal adhesions are the leading cause of pelvic pain, bowel obstruction, and infertility. Although some patients develop limited scar tissues, others for unknown reasons develop severe adhesions from seemingly equal procedures. Additionally in the same patient, adhesions develop at one surgical site but not in another. The mechanisms underlying the predisposition to form scars as well as their site specificity are unknown. Because a large number of intraperitoneal surgical procedures are performed each day, many patients are at risk of developing postoperative adhesions. As such, understanding the nature of molecular events and their mechanisms of action is essential, and in the absence of such information, attempts to prevent patients from developing adhesions will remain an empirical process. An unprecedented advancement in surgical techniques have resulted in minimizing peritoneal tissue injury that cause adhesion formation. Increased understanding of the cellular and molecular events that lead to scar tissue formation has also led to the identification of many biologically active molecules with the potential of regulating inflammatory and immune responses, angiogenesis, and tissue remodeling, events that are central to normal peritoneal wound healing and adhesion formation. This article attempts to highlight some of the key molecules (i.e., the transforming growth factor family and its regulatory mechanisms) that are recognized to regulate peritoneal wound repair and adhesion formation. Such understanding of peritoneal biology not only will assist us to better manage patients with adhesions but also will assist those with endometriosis and malignant diseases that affect the peritoneal cavity.

Zhonghua Yi Xue Za Zhi. 2008 Apr 15;88(15):1032-5.

[Association between susceptibility of endometriosis and the gene polymorphism of tumor necrosis factor]

[Article in Chinese]

Lu DH, Lin J, Deng L.

Affiliated Obstetrical and Gynecological Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China.

OBJECTIVE: To evaluate the association between the susceptibility of endometriosis (EMS) and the gene polymorphism of tumor necrosis factor (TNF) in Chinese Han population. METHODS: Peripheral blood samples were collected from 76 EMS patients and 87 normal controls. PCR-RFLP was used to detect the single base change polymorphism in both TNFalpha gene and TNFbeta gene. RESULTS: The allele frequencies of the TNFalpha polymorphism were 0.9474 and 0.9253 in the EMS patients and the control group respectively, and the TNFbeta polymorphism were 0.0526 and 0.0747 respectively. The allele frequencies of the TNFbeta1 polymorphism were 0.4605 and 0.5115 in the EMS patients and the control group, and the TNFbeta2 polymorphism were 0.5395 and 0.4885. No difference in the gene and genotype frequencies of TNFalpha and TNFbeta was noted in the EMS patients and normal controls (all P > 0.05). CONCLUSION: TNF gene polymorphism has no effect on EMS in Chinese Han population. Ethnic difference may exist in TNF allele frequency.

Clin Exp Obstet Gynecol. 2008;35(3):231-2.

Successful treatment of advanced endometriosis with extremely high CA 125 and moderately elevated CA 15-3 levels.

Canda MT, Demir N, Sezer O, Doganay L.

Department of Obstetrics and Gynecology, Kent Hospital, Izmir, Turkey. candatunc@yahoo.com

We present the case of a patient with advanced endometriosis who presented with chronic pelvic pain, bilateral unruptured ovarian endometrioma, massive peritoneal implants and extremely elevated CA 125, and also elevated CA 15-3 levels. Laparoscopy revealed bilateral unruptured ovarian endometrioma and diffuse peritoneal endometriotic implants. Increased association of elevated levels of CA 125 and CA 15-3 is not so common in advanced endometriosis. The case was successfully treated with laparoscopy and combined low-dose oral contraceptive with one year of follow-up. To the best of our knowledge among the reported cases this is the highest CA 15-3 level ever reported with an extremely elevated CA 125 level.

Nan Fang Yi Ke Da Xue Xue Bao. 2008 Aug;28(8):1463-5.

[Effect of laparoscopic surgery on the immune function of patients with endometriosis]

[Article in Chinese]

Xu JZ, Chen FH.

Department of Obstetrics and Gynecology, Huadu Poeple’s Hospital Affiliated to Southern Medical University, Guangzhou, China. xuzhong0909 @126.com

OBJECTIVE: To investigate the effect of laparoscopic surgery on the immune function of patients with endometriosis. METHOD: Blood samples were obtained from 36 patients undergoing laparoscopy for endometriosis before and 1 day and 3 days after the operation. Peripheral blood T-cell subsets CD3, CD4, and CD8 were determined with flow cytometry, the levels of IgM, IgG, IgA, Complement (C)3, C4, C-reactive protein and (CRP) were detected with turbidimetry, and the levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) were measured with enzyme linked immunosorbent assay (ELISA). RESULTS: No significant variation were found in the T-cell subsets, IgM, IgA, C4 after the operation (P>0.05). The levels of IgG and C3 1 day after the operation were significantly lower than the preoperative levels (P<0.05) and nearly recovered the preoperative level 3 days after operation. Serum concentration of IL-6, TNF-alpha, and CRP 1 day after the operation were significantly higher than the preoperative levels (P<0.01) and decreased 3 days after the operation. CONCLUSIONS: The immune function of patients with endometriosis is mildly affected by laparoscopic surgery and recover rapidly, which may be one of the reasons for quick recovery of patients after laparoscopy for endometriosis.

BJOG. 2008 Dec;115(13):1605-10. Epub 2008 Aug 25.

Comment in:

BJOG. 2008 Dec;115(13):1597-600.

BJOG. 2009 Jun;116(7):1004-5.

Long-term outcomes following laparoscopic supracervical hysterectomy.

Lieng M, Qvigstad E, Istre O, Langebrekke A, Ballard K.

Department of Gynaecology and Obstetrics, Ullevål University Hospital, Oslo, Norway. m.lieng@online.no

OBJECTIVE: Evaluation of long-term outcomes following laparoscopic supracervical hysterectomy (LSH). DESIGN: Retrospective postal questionnaire. SETTING: Norwegian university teaching hospital. POPULATION: A total of 315 consecutive patients. METHODS: A questionnaire sent to all patients who underwent a LSH during 2004 and 2005. MAIN OUTCOME MEASURES: Persistent vaginal bleeding and pelvic pain, patient acceptability of such symptoms and patient satisfaction following LSH. RESULTS: A total of 240 women (78%) completed the questionnaire. About 24% reported experiencing vaginal bleeding up to 3 years following their hysterectomy, although this was rated as minimal in 90% of cases, resulting in a mean bothersome score of 1.1 (SD 2.0) on a 10-point visual analogue scale (VAS). Women operated on by less experienced surgeons were more likely to report vaginal bleeding following surgery (P = 0.02). About 74% of women reported having menstrual pain prior to surgery, with a mean score of 6.8 (SD 2.1) (10-point VAS). Up to 3 years following surgery, 38% continued to experience menstrual pain, although this was significantly less intense with a mean score of 3.5 (SD 2.2) (P < 0.01). While all women reported a decrease in the amount of pain experienced following the hysterectomy, those having a hysterectomy because of endometriosis reported significantly higher levels of menstrual/cyclical pain after surgery compared with women who had a hysterectomy for other reasons (P < 0.01). Ninety per cent of women reported being satisfied with their surgery. CONCLUSION: Although vaginal bleeding and pelvic pain are frequently observed following LSH, these symptoms are significantly reduced and patient satisfaction is high.

Pathology. 2008 Oct;40(6):592-9.

WT1 expression in endometrioid ovarian carcinoma with and without associated endometriosis.

Stewart CJ, Brennan BA, Chan T, Netreba J.

Department of Histopathology, King Edward Memorial Hospital, Bagot Road, Subiaco, Perth, WA 6009, Australia. colin.stewart@health.wa.gov.au

AIMS: To determine how frequently endometrioid ovarian carcinomas (EOC) express WT1 protein, and to correlate the results with the presence of endometriosis and p53 immunoreactivity. METHODS: Forty-one grade 1-2 EOC were stained immunohistochemically for WT1 and p53 proteins. Twenty-one tumours were associated with endometriosis and 20 cases lacked such an association. WT1 expression in the tumour cell nuclei and/or cytoplasm was recorded. Nuclear p53 staining was assessed as diffuse (>50% cells positive), focal, or negative. RESULTS: Four of the 20 (20%) tumours in the endometriosis negative group showed nuclear WT1 staining, while none of the endometriosis-associated EOC was positive (p < 0.05). Two of the immunoreactive cases exhibited sertoliform/sex cord-like patterns. Focal cytoplasmic WT1 labelling was present in seven EOC, three of which showed sertoliform, spindle cell or corded and hyaline patterns. There was no correlation between WT1 expression and p53 immunoreactivity. CONCLUSIONS: Nuclear WT1 expression is present in a minority of EOC and this should be considered if immunohistochemistry is used as an adjunct in sub-typing ovarian carcinomas. The negative correlation of WT1 staining with endometriosis supports the possibility that some EOC, including unusual histological variants, arise from the ovarian surface epithelium. Further studies of EOC should document any association with endometriosis.

Acta Obstet Gynecol Scand. 2008;87(10):1077-80.

Ultrasonographically guided transvaginal hydrolaparoscopy.

Sobek A Jr, Hammadeh M, Vodicka J, Sobek A.

FERTIMED, Infertility Center, Boleslavova, Olomouc, Czech Republic.

Transvaginal hydrolaparoscopy was introduced as an outpatient procedure to examine the tubo-ovarian complex in infertile women. We evaluated ultrasonographically guided transvaginal hydrolaparoscopy (UTHL) as a modified technique for pelvic examination in 562 infertile women without overt evidence of pelvic pathology. Access to the abdominal cavity was observed by ultrasound and examination of the pelvic structures was done by hydrolaparoscopy using saline solution. Access was successful in all cases. No perforation of bowel or rectum was detected. Bilateral visualization of the tubo-ovarian complex was successful in 96% of women. Mild asymptomatic peri-ovarian adhesions were detected in 17% of the women, 4.9% had grade I endometriosis. There was unilateral tubal occlusion in 5%, and bilateral in 3.6%. In 13.9% elective operative laparoscopy for tubal obstruction and/or adhesions was recommended. UTHL is a safe outpatient procedure for examination of the tubo-ovarian complex. The use of ultrasound increases the rate of successful access to the pouch of Douglas and minimizes complications.

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