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Latest Research on Endometriosis
     
Eur J Obstet Gynecol Reprod Biol. 2008 Feb 1 [Epub ahead of print]
Endometriosis and infertility Surgery and ART: An integrated approach for successful management.
Coccia ME, Rizzello F, Cammilli F, Bracco GL, Scarselli G.
Department of Gynaecology, Perinatology and Human Reproduction, University of Florence, Viale Morgagni 85, 50134 Florence, Italy.

OBJECTIVE(S): Laparoscopy is considered the gold standard for treatment of endometriosis. In vitro fertilization and embryo transfer (IVF-ET) is often used to treat women with infertility associated with endometriosis. The objective of the study was to evaluate the pregnancy rate after surgical treatment and to assess whether a combined approach with laparoscopic surgery followed by IVF-ET can improve the "overall" pregnancy rate. STUDY DESIGN: A retrospective observational study was carried out on 107 infertile patients who underwent laparoscopic surgery for endometriosis and came at follow-up for a period of time between 1 and 11 years. Sixty-seven patients who did not become pregnant after surgery subsequently underwent IVF-ET. RESULTS: The pregnancy rate achieved after the integrated laparoscopy-IVF approach was 56.1%. The pregnancy rate after surgery, was significantly lower (37.4%). The fecundity rate for spontaneous conceptions within 6 months of laparoscopy (23.2%) was significantly higher (P<0.05) than for the following intervals. The cumulative fecundity in women older than 35 years was significantly lower than in younger women. CONCLUSION(S): In patients with endometriosis-associated infertility, surgery followed by IVF-ET is more effective than surgery alone. When patients fail to conceive spontaneously, after a maximum of 1 year from laparoscopic surgery, IVF should be suggested.

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Expert Opin Pharmacother. 2008 Feb;9(2):243-55.
Treatment strategies for endometriosis.
Rodgers AK, Falcone T.
Department of Obstetrics and Gynecology, The Cleveland Clinic, Department of Obstetrics and Gynecology-A81, 9500 Euclid Avenue, Cleveland, Ohio 44159, USA.

BACKGROUND: Endometriosis is a common chronic disease that causes symptoms of pain and infertility. The pain syndrome can be quite incapacitating. The pain symptoms usually originate in the reproductive organs but can also involve the urinary or intestinal tracts if endometriosis implantation has occurred there. The presentation and physical appearance of endometriosis is extremely variable and can be characterized by a chronic intraperitoneal inflammatory process and adhesions. The only definitive diagnostic technique is laparoscopy. OBJECTIVE: To review current literature on the treatment strategies for endometriosis. METHODS: Review of Pubmed, Cochrane database and Medline for current review articles and studies regarding the current treatment strategies for endometriosis. RESULTS: Initial treatment is surgical or medical. Medical therapy is often used as a first-line therapy and can also be used in conjunction with those patients who undergo surgical therapy for pain. No medical therapy has proven effective for infertility. Medical therapy consists mostly of hormonal suppressive therapy in which the medication causes a downregulation of the hypothalamus-pituitary-ovarian pathway. Non-steroidal anti-inflammatory drugs and oral contraceptives are often used as an initial approach even without a definitive diagnosis. Progestins, such as oral norethindrone and depot medroxyprogesterone, are effective while using them but have a high recurrence rate. The norgestrol intrauterine device is also quite effective at relieving pain associated with endometriosis, especially pain arising during menses as well as from lesions in the rectovaginal tissue. Gonadotropin-releasing hormone agonists induce a pseudomenopausal state and have significant side effects, such as hot flashes and genital atrophy. 'Add-back' therapy with a progestin has been shown to relieve most of these drug related symptoms. Gonadotropin-releasing hormone agonists are also very effective at relieving symptoms of pain during treatment but are also associated with a high recurrence rate. New drug therapies that are under investigation are aromatase inhibitors and immunomodulators. Furthermore, new delivery systems are being investigated that may also improve the patient response.

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Rev Mal Respir. 2007 Dec;24(10):1329-40.
[Thoracic endometriosis.]
[Article in French]
Nunes H, Bagan P, Kambouchner M, Martinod E.
Service de Pneumologie, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, UFR SMBH, Université Paris 13, 93009 Bobigny, France.

INTRODUCTION: Endometriosis is defined as the abnormal presence of endometrial tissue, including endometrial glands and stroma, outside the uterine cavity. The term "thoracic endometriosis" is classically referred to the respiratory manifestations which classically result from the presence and the cyclical changes of endometrial tissue in one of the thoracic structures. STATE OF ART: Although thoracic endometriosis is rare, four clinical entities are well-recognized: pneumothorax, hemothorax, haemoptysis and pulmonary nodule, with a respective frequency of 73%, 14%, 7% and 6%. These are characterized by the recurrence of symptoms within the menstruations, in women aged between 30 and 40, and mainly in the right hemi-thorax. Pelvic endometriosis is usually, if not constantly, associated. Catamenial pneumothorax is not always related to thoracic endometriosis and its mechanisms remain unclear. An exploratory and therapeutical surgery is required in most of the cases. Video-assisted-thoracoscopy is the best current approach of catamenial pneumothorax. It may visualize pathognomonic pleuro-diaphragmatic abnormalities, including diaphragmatic fenestrations and/or endometrial implants, in about one third of the patients. Surgical treatment is justified because of the frequent relapses under medical treatment alone. Surgery consists of diaphragmatic repair and excision of all apparent endometrial implants; pleural abrasion may complete the procedure. A combined prolonged hormonal therapy is increasingly recommended, Danazol or GnRH analogs being advantaged. PERSPECTIVES: Further prospective studies are needed to estimate the real incidence of thoracic endometriosis and to devise the best therapeutical option. CONCLUSIONS: Thoracic endometriosis is probably rare but its diagnosis is easy when accurately raised. The approach is multidisciplinary involving a pneumologist, a thoracic surgeon and a gynecologist.

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Clin Obstet Gynecol. 2007 Dec;50(4):886-97.
The Levonorgestrel-releasing Intrauterine System: An Updated Review of the Contraceptive and Noncontraceptive Uses.
Chrisman C, Ribeiro P, Dalton VK.
Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan.

The levonorgestrel containing intrauterine system is an effective and safe form of long-term yet reversible birth control. Intrauterine contraception use in the United States fell dramatically after early studies reported an association between intrauterine contraception use and later tubal infertility. Subsequent evaluation suggests that these early studies were biased. Users often experience menstrual disturbances. Informing patients of these common side effects is important to improve compliance. In addition to its contraceptive effect, the levonorgestrel intrauterine system offers potential therapeutic benefits in other clinical contexts, including menorrhagia, symptomatic fibroids, endometriosis, and endometrial suppression.

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Best Pract Res Clin Obstet Gynaecol. 2007 Nov 2; [Epub ahead of print]
Intravaginal oestrogen and progestin administration: advantages and disadvantages.
Cicinelli E.
4th Department of Obstetrics and Gynecology, University of Bari, Policlinico, Piazza Giulio Cesare, 70124 Bari, Italy.

The vagina provides a local and a systemic route for delivering hormones for systemic effects and uterine targeting. Due to the 'uterine first-pass effect', hormones concentrate in the uterus and nearby tissues with low systemic exposure. Vaginal oestrogens, progesterone/progestins and danazol are currently used to obtain local (vagina and urethra), regional (uterus, pelvic structures) and systemic effects or contraception. Very low dosages of transvaginal oestrogens in the forms of creams, tablets and rings are effective for vaginal atrophy and urinary incontinence. To avoid endometrial stimulation, no deep vaginal application of low dosages for less than 6 months is recommended. For postmenopausal hormonal therapy by the vaginal route, progesterone is delivered directly to the uterus; the target organ for which it is designed. Worldwide, vaginal progesterone is employed for luteal phase support. Contraceptive vaginal rings offer the advantages of non-oral administration and sustained release. Vaginal administration of steroids is a promising option for the treatment of endometriosis.

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Am J Obstet Gynecol. 2007 Nov;197(5):501.e1-4.
Severe intraabdominal bleeding caused by endometriotic lesions during the third trimester of pregnancy.
Katorza E, Soriano D, Stockheim D, Mashiach R, Zolti M, Seidman DS, Schiff E, Goldenberg M.
Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Israel.

OBJECTIVE: Endometriosis is known to be associated with an increased risk for early pregnancy complications, including ectopic pregnancy and miscarriage. However, little has so far been reported on complications linked to severe endometriosis occurring during the third trimester of pregnancy. STUDY DESIGN: A retrospective review of 800 women attending the endometriosis clinic of the Sheba Medical Center during the years 2002-2006 was performed. Cases with severe endometriosis and associated complications during late pregnancy were identified. RESULTS: Three women were found who experienced significant intraabdominal bleeding in the third trimester of pregnancy attributed to a lesion resulting from severe endometriosis. The intraabdominal bleeding occurred between 26-29 weeks of gestation. In all cases the major presenting prenatal symptom was severe lower abdominal pain. The pain was not relieved by the administration of tocolytics or mild analgesics. Explorative laparotomy, performed in all 3 cases, revealed the presence of significant intraabdominal bleeding requiring immediate transfusion of blood products stemming from endometriotic lesions. Fetal complications occurred in all 3 cases. CONCLUSION: The symptoms of endometriosis are often relieved during pregnancy. Yet lesions caused by severe endometriosis can lead to significant intraabdominal bleeding during the third trimester of the pregnancy. Physicians must be aware that close antenatal follow-up and prompt intervention may be required in such cases.

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Cochrane Database Syst Rev. 2007 Oct 17;(4):CD000068.
Danazol for pelvic pain associated with endometriosis.
Selak V, Farquhar C, Prentice A, Singla A.

BACKGROUND: Endometriosis is defined as the presence of endometrial tissue (stromal and glandular) outside the normal uterine cavity. Conventional medical and surgical treatments for endometriosis aim to remove or decrease the deposits of ectopic endometrium. The observation that hyper androgenic states (an excess of male hormone) induce atrophy of the endometrium has led to the use of androgens in the treatment of endometriosis. Danazol is one of these treatments. The efficacy of danazol is based on its ability to produce a high androgen and low oestrogen environment (a pseudo menopause) which results in atrophy of the endometriotic implants and thus an improvement in painful symptoms. OBJECTIVES: To determine the effectiveness of danazol compared to placebo or no treatment in the treatment of the symptoms and signs, other than infertility, of endometriosis in women of reproductive age. SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials (searched April 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2007), and MEDLINE (1966 to April 2007). In addition, all reference lists of included trials were searched, and relevant drug companies were contacted for details of unpublished trials. SELECTION CRITERIA: Randomised controlled trials in which danazol (alone or as adjunctive therapy) was compared to placebo or no therapy. Trials which only reported infertility outcomes were excluded. DATA COLLECTION AND ANALYSIS: Only five trials met the inclusion criteria and two authors independently extracted data from these trials. All trials compared danazol to placebo. Three trials used danazol as sole therapy and three trials used danazol as an adjunct to surgery. Although the main outcome was pain improvement other data relating to laparoscopic scores and hormonal parameters were also collected. MAIN RESULTS: Treatment with danazol (including adjunctive to surgical therapy) was effective in relieving painful symptoms related to endometriosis when compared to placebo. Laparoscopic scores were improved with danazol treatment (including as adjunctive therapy) when compared with either placebo or no treatment. Side effects were more commonly reported in those patients receiving danazol than for placebo. AUTHORS' CONCLUSIONS: Danazol is effective in treating the symptoms and signs of endometriosis. However, its use is limited by the occurrence of androgenic side effects.

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Acta Obstet Gynecol Scand. 2007 Sep 4;:1-7 [Epub ahead of print]
Postmenopausal endometriosis.
Oxholm D, Knudsen UB, Kryger-Baggesen N, Ravn P.
Department of Gynaecology and Obstetrics, Odense University Hospital, University of Southern Denmark, Denmark.

Background. Postmenopausal endometriosis is rare. The purpose of this presentation is to give a review of the topic based on existing literature. Methods. A Medline search concerning postmenopausal endometriosis was carried out. Hormone therapy and risk of malignancy in these patients are discussed. Results. Some 32 case reports on postmenopausal endometriosis were found. The most common location is in the ovaries. Estrogens stimulate endometriosis. There is a risk of recurrence or de novo occurrence of endometriosis after the menopause in patients who take hormone therapy (HT); especially estrogen only therapy (ET). So far, treatment has primarily been surgery (hysterectomy (TAH) and bilateral oophorectomy (BSO)). There is little experience with medical treatment (aromatase inhibitors). The risk of malignant transformation of premenopausal endometriosis is around 1%. Furthermore, patients with endometriosis have an increased risk of ovarian cancer, and, apparently, other malignancies. The risk of malignant transformation appears to be further elevated in patients who take ET, although this subject is not fully elucidated. Conclusions. Although the condition is rare, it is important to be aware of endometriosis after the menopause. Postmenopausal endometriosis infers a risk of recurrence and malignant transformation. Although solid evidence is lacking, the risk of malignant transformation appears to be lower during combined HT compared to ET. Thus, hormone replacement therapy should generally be reserved for patients with severe climacteric complaints, and if indicated, combined therapy should be used.

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Acta Obstet Gynecol Scand. 2007;86(12):1467-71. Epub 2007 Sep 6.
Laparoscopic laser resection of rectovaginal pouch and rectovaginal septum endometriosis: the impact on pelvic pain and quality of life.
Kristensen J, Kjer JJ.
Department of Gynaecology, Glostrup University Hospital, Denmark.

Background. The aim of this study was to assess the impact on pelvic pain and quality of life of laparoscopic resection of the rectovaginal pouch (RV) and RV septum in patients with endometriosis. Methods. The design was a descriptive retrospective study. The study included 48 women presenting to the Department of Obstetrics and Gynaecology with RV pouch and RV septum endometriosis, between 1 January 2003 and 1 January 2006. The setting was a university teaching hospital, one of two referral centres in Denmark for the surgical treatment of stage III and IV endometriosis. Questionnaires and Visual Analogue Scale (VAS) scores for a number of different symptoms associated with endometriosis were used. The main outcome measures were: effect of laparoscopic excision on pain scores and quality of life, operative findings, type of surgery, duration of surgery, and incidence of intra- and postoperative complications. Results. Significant statistical differences were found between preoperative and postoperative pain scores, quality of life, frequency of sexual activity, percentage taking analgesics or non-steroidal anti-inflammatory drugs, percentage having work difficulties due to pain, and percentage of women having sick-leave. Conclusion. Endometriosis in the RV pouch and RV septum can be effectively treated with laser laparoscopy performed by experienced endoscopic gynaecologists.

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Best Pract Res Clin Obstet Gynaecol. 2007 Aug 29; [Epub ahead of print]
Hormonal treatments for adenomyosis.
Fedele L, Bianchi S, Frontino G.
Fondazione Policlinico, Mangiagalli e Regina Elena,Clinica Ostetrica e Ginecologica II, Università di Milano, Istituto Luigi Mangiagalli, Via della Commenda 12, 20122 Milano, Italy.

Like endometriosis and uterine myomas, adenomyosis presents the typical characteristics of oestrogen-dependent diseases. The medical treatment of adenomyosis is based on the hormonal dependency of the disease and its strongly debated similarities with endometriosis. Infact, despite the evident differences between the two conditions, the therapies that treat endometriosis effectively have also been successful for the treatment of adenomyosis. Although the two diseases have distinct epidemiological features, they have the same 'target tissue' for hormonal therapy, namely ectopic endometrium. Recognized approaches are systemic hormonal treatments, which are generally used for endometriosis and are capable of suppressing the oestrogenic induction of the disease, and local hormonal treatment that targets the ectopic endometrium directly. Gonadotropin-releasing hormone agonists, danazol and intrauterine levonorgestrel- or danazol-releasing devices have been used in the treatment of adenomyosis. Despite the solid rational basis for its hormonal treatment, few studies have been performed on medical therapy for adenomyosis.

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Surg Endosc. 2007 Aug 19; [Epub ahead of print]
Combined vaginal-laparoscopic-abdominal approach for the surgical treatment of rectovaginal endometriosis with bowel resection: a comparison of this new technique with various established approaches by laparoscopy and laparotomy.
Zanetti-Dällenbach R, Bartley J, Müller C, Schneider A, Köhler C.
Department of Gynecology, Universitätsmedizin Berlin, Berlin, Germany.

BACKGROUND: A new combined vaginal-laparoscopic-abdominal approach for rectovaginal endometriosis allows intraoperative digital bowel palpation to assess bowel infiltration and prevents unnecessary bowel resections. This technique was compared to various established approaches where bowel resection was indicated by clinical symptoms and imaging results only. METHODS: Patients operated for rectovaginal endometriosis with endometriotic bowel involvement between March 2002 and April 2006 at the gynecological department Charité, Berlin, Germany were included. Bowel involvement was suspected by clinical symptoms, clinical examination, and/or results of imaging techniques. The study group (SG) was operated by the combined vaginal-laparoscopic-abdominal approach (n = 30) and the control group (CG) (n = 18) by laparoscopy (n = 4), laparotomy (n = 3), laparoscopy followed by laparotomy for bowel resection (n = 8) or laparoscopy followed by vaginal bowel resection (n = 3). In all cases histopathology was performed. RESULTS: The study group and the control group were comparable regarding age, body mass index, symptoms, American Society for Reproductive Medicine (ASRM) classification, colorectal operative procedures, operating times, length of the resected bowel specimen, and concomitant surgical procedures. However, only in the CG were protective stomas required (p = 0.047). There were significantly less complications in the SG (p = 0.027). No patient experienced leakage of anastomosis. Bowel involvement by endometriosis was confirmed by histopathology in the SG in all cases whereas in the CG only in 16/18 (88.9%) cases. Hospitalization time was significantly shorter in the SG. Rehospitalizations were necessary only in the CG to repair one rectovaginal fistula and to reverse three stomas. CONCLUSIONS: With the presented technique of a combined vaginal-laparoscopic-abdominal surgical procedure for rectovaginal endometriosis, we showed that the complication rate, rehospitalization rate, and hospitalization time were significantly lower than in the patients of the CG. Furthermore, the combined vaginal-laparoscopic-abdominal technique allowed better evaluation of the invasiveness of the endometriotic lesion and avoided unnecessary bowel surgery.

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Aust N Z J Obstet Gynaecol. 2007 Jun;47(3):222-5.
Letrozole and desogestrel-only contraceptive pill for the treatment of stage IV endometriosis.
Remorgida V, Abbamonte LH, Ragni N, Fulcheri E, Ferrero S.
Department of Obstetrics and Gynaecology, San Martino Hospital and University of Genoa, Genoa, Italy.

Background: It has recently been suggested that aromatase inhibitors may effectively reduce pain symptoms related to the presence of endometriosis both in postmenopausal women and in subjects of reproductive age. Aims: This study aims to evaluate the effectiveness of a combination of letrozole and desogestrel in the treatment of pain symptoms related to the presence of endometriosis. Methods: This open-label prospective study included 12 women with endometriosis-related pain symptoms that were refractory to previous medical and surgical treatments. All women had previous laparoscopy documenting stage IV endometriosis. The treatment protocol included the daily oral administration of letrozole 2.5 mg (Femara(R)), desogestrel 75 microg (Cerazette(R)), elemental calcium 1000 mg and vitamin D 880 I.U. The scheduled treatment period was six months. Results: None of the women included in the study completed the six-month treatment because all patients developed ovarian cysts; the median length of treatment was 84 days (range, 56-112). At interruption of treatment, all women reported significant improvements in dysmenorrhoea and dyspareunia. Pain symptoms quickly recurred at three-month follow up. There were no severe adverse effects of treatment; no significant change in the mineral bone density was observed during treatment. Conclusions: The combination of letrozole and desogestrel induces a relief of pain symptoms in women with endometriosis but it causes the development of ovarian cysts. Pain symptoms quickly recur after the completion of treatment.

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Fertil Steril. 2007 Jun 1; [Epub ahead of print]
Efficacy of vaginal danazol treatment in women with recurrent deeply infiltrating endometriosis.
Razzi S, Luisi S, Calonaci F, Altomare A, Bocchi C, Petraglia F.
Division of Obstetrics and Gynecology, Department of Pediatrics, Gynecology and Reproductive Medicine, University of Siena, Siena, Italy.

OBJECTIVE: To describe a safe long-term medical treatment for deeply infiltrating endometriosis, a critical condition characterized by multiple painful symptoms and a high recurrence rate after surgical treatment. DESIGN: Prospective study. SETTING: University of Siena. PATIENT(S): Twenty-one women with deeply infiltrating endometriosis. INTERVENTION(S): In a nonrandomized prospective study a low dose of vaginal danazol (200 mg/d) was self-administered for 12 months. After a previous laparoscopic surgery, these patients had reported recurrent severe dyspareunia, dysmenorrhea, and pelvic pain (in five cases also painful defecation). MAIN OUTCOME MEASURE(S): Before and every 3 months during the treatment a visual analogue pain scale was used. Transvaginal and transrectal ultrasound examinations were performed before and after 6 and 12 months of treatment. Adverse effects were registered, and serum concentration of cholesterol, triglycerides, aspartate aminotransferase, alanine aminotransferase, glycemia, protein S, protein C, antithrombin III, and homocysteine was evaluated before and after 12 months. RESULT(S): Dysmenorrhea, dyspareunia, and pelvic pain significantly decreased within 3 months and disappeared after 6 months of treatment, with a persistent effect during the 12 months of treatment. A relief of painful defecation was also shown. Ultrasound examination showed a reduction of the nodularity in the rectovaginal septum within 6 months. The medical treatment did not affect metabolic or thrombophilic parameters; few local vaginal adverse effects were reported. CONCLUSION(S): Vaginal danazol resulted in effective medical treatment for the various painful symptoms in women with recurrent deeply infiltrating endometriosis, and because of the lack of significant adverse effects it may be proposed as an alternative to repeated surgery.

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Contraception. 2007 Jun;75(6 Suppl):S134-9. Epub 2007 Feb 16.
Use of the levonorgestrel-releasing intrauterine system in women with endometriosis, chronic pelvic pain and dysmenorrhea.
Bahamondes L, Petta CA, Fernandes A, Monteiro I.
Human Reproduction Unit, Department of Obstetrics and Gynecology, School of Medicine, Universidade Estadual de Campinas (UNICAMP), 13084-971, Campinas, SP, Brazil.

OBJECTIVES: This report is a review of the medical literature on the use of the levonorgestrel-releasing intrauterine system (LNG-IUS(R)) in women with endometriosis, adenomyosis, cyclic pelvic pain and dysmenorrhea. MATERIAL AND METHODS: A review was carried out using the MEDLINE and EMBASE databases to evaluate the use of LNG-IUS(R) in women with endometriosis and adenomyosis. RESULTS: Nine studies were identified, only two of which were randomized clinical trials. One compared the insertion of LNG-IUS(R) after surgery with expectant conduct and the other compared the use of the device with a GnRH analogue (GnRH-a). All studies reported an improvement in pelvic pain and dysmenorrhea, and a reduction in menstrual bleeding. One study found an improvement in the staging of the disease at 6 months of use, and the studies that evaluated the use of LNG-IUS(R) in women with adenomyosis reported a reduction in uterine volume. Furthermore, the only study in which women were followed up for 3 years after insertion found improvement in pelvic pain at 12 months of use. However, there was no improvement after that period. CONCLUSIONS: The use of LNG-IUS(R) is an alternative for the medical treatment of women suffering from endometriosis, adenomyosis, chronic pelvic pain or dysmenorrhea, but experience is limited and long-term studies are necessary to reach definitive conclusions. However, for women who do not wish to become pregnant, this device offers the possibility of at least 5 years of treatment following one single intervention.

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J Gynecol Obstet Biol Reprod (Paris). 2007 Jun;36(4):354-359. Epub 2007 Mar 30.
[Reproductive outcome after laparoscopic treatment of endometriosis in an infertile population.]
[Article in French]
Fuchs F, Raynal P, Salama S, Guillot E, Le Tohic A, Chis C, Panel P.
Service de gynécologie obstétrique, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le-Chesnay, France.

OBJECTIVES: To evaluate fertility outcome after laparoscopic management of endometriosis in an infertile population. MATERIALS AND METHODS: A retrospective analysis of 64 patients presenting more than one year infertility and a pregnancy-wish associated with minimal to severe endometriotic lesions (stage I to IV according to the revised American Fertility Society (rAFS) classification), treated using laparoscopic surgery in order to remove the entire lesions. We excluded women under 20 years and over 40, as well as those with other infertility factors (tubal non endometriosis-related, hormonal or sperm). Fertility of the remaining 34 patients was studied in relation to endometriosis stage and to pregnancy's mode (spontaneous or induced). RESULTS: Pregnant women percentage was 65% (22 patients) within a 8.5 months (quartiles: 3; 15.5) [range: 1; 52] post-surgical time, and 86.5% pregnancies issued with a delivery. The rate of pregnant women depended on stage of endometriosis (89% for stages I-II, and 56% for stages III-IV). Sixty percent pregnancies were spontaneous within a 5 months (3; 9) [1; 52] post-surgical time to pregnancy average. When pregnancies were obtained with assisted reproductive techniques, the median post-surgical time to pregnancy was 12 months (9; 22) [2; 31]. Among women with stages I-II endometriosis, the median post-surgical time to pregnancy was 2 months when spontaneous and 20.5 months when induced (P=0.007). In case of stages III-IV endometriosis, pregnancy's delay was 8 and 12 months respectively (P=0.79). Among the 21% women who had had an induced pregnancy failure before surgery, 71% became pregnant and 80% spontaneously. Eighteen patients (53%) had an ovarian endometrioma and 50% of them became pregnant. Among the 4 patients who had colorectal endometriosis requiring colorectal resection, 1 pregnancy was obtained. CONCLUSIONS: These findings suggest that in a context of more than one year infertility only related to endometriosis, it is reasonable to offer these patients a complete operative laparoscopic treatment of their lesions, which enables 65% of them to be pregnant within a 8.5 months post-surgical median time to pregnancy and spontaneously in 60%. In case of stages I-II endometriosis we suggest a spontaneous pregnancy try during 8 to 12 months before starting induced pregnancy therapeutics instead of stages III-IV endometriosis where induced methods should be used after only 6 or 8 months.

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BJOG. 2007 May 15; [Epub ahead of print]
Surgical outcome and long-term follow up after laparoscopic rectosigmoid resection in women with deep infiltrating endometriosis.
Seracchioli R, Poggioli G, Pierangeli F, Manuzzi L, Gualerzi B, Savelli L, Remorgida V, Mabrouk M, Venturoli S.
Center of Reconstructive Pelvic Endo-surgery, Reproductive Medicine Unit, University of Bologna, Bologna, Italy.

The aim of this study was to assess the long-term outcome of treating severely symptomatic women with deep infiltrating intestinal endometriosis by laparoscopic segmental rectosigmoid resection. Detailed intraoperative and postoperative records and questionnaires (preoperatively, 1 month postoperatively and every 6 months for 3 years) were collected from 22 women. The estimated blood loss during surgery was 290 +/- 162 ml (range 180-600), and average hospital stay was 8 days (range 6-19). One woman required blood transfusion after surgery. Two cases were converted to laparotomy. One woman had early dehiscence of the anastomosis. Six months after surgery, there was a significant reduction of symptom scores (greater than 50% for most types of pain) related to intestinal localisation of endometriosis (P < 0.05). Score improvements were maintained during the whole period of follow up. Noncyclic pelvic pain scores showed significant reductions (P < 0.05) after 6 and 12 months, but there was a high recurrence rate later. Dysmenorrhoea and dyspareunia improved in 18/21 and 14/18 women with preoperative symptoms, respectively. Constipation, diarrhoea and rectal bleeding improved in all affected women for the whole period of follow up. Laparoscopic segmental rectosigmoid resection seems safe and effective in women with deep infiltrating colorectal endometriosis resulting in significant reductions in painful and dysfunctional symptoms associated with deep bowel involvement.

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ANZ J Surg. 2007 May;77(s1):A15.
CR02 Rectal endometriosis: The results of radical excision.
Brouwer R, Woods R.
St. Vincent’s Hospital, Victoria, Australia.

Background The aim of this paper is to review the results of radical surgical excision of rectal endometriosis. Methods All cases of endometriosis involving the rectum treated by a single colorectal surgeon were identified from a prospective database and the results reviewed. Results Between 1995 and 2005, 213 rectal procedures were performed on 203 patients together with an endo-gynaecologist. 18 cases involved dissection of endometriosis off the rectal wall, 58 involved full-thickness excision of the anterior rectal wall and 137 segmental excisions of the rectum were performed. The mean follow-up was 68 months (range 7-158 months). A loop ileostomy was required in 7 (5 percent) of the segmental resections. 75 percent of cases were laparoscopic. Infertility was significantly more common in the group requiring a segmental resection (P = .026) and a history of rectal pain during defecation more common in patients having dissection of endometriosis off the rectal wall (P = .031). There were no other significant differences in symptoms between the different types of rectal surgery. The morbidity for all rectal procedures was 7 percent and there was no significant difference in complication rate between the different groups. The overall rectal recurrence rate was 5 percent and was significantly more common in the group who had dissection of the endometriosis off the rectal wall (P = .004). Conclusions Endometriosis of the rectum can be successfully treated with low morbidity and low recurrence rates by excising the disease as completely as possible using full-thickness excision of the anterior rectal wall or segmental resection of the rectum.

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Eur J Gynaecol Oncol. 2007;28(2):77-82.
Robotic surgery in gynecology.
Magrina JF.
Director Division of Gynecologic Oncology Department of Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Scottsdale, AZ 85259, USA.

Robotic technology is nothing more than an enhancement along the continuum of laparoscopic technological advances and represents only the beginning of numerous more forthcoming advances. It constitutes a major improvement in the efficiency, accuracy, ease, and comfort associated with the performance of laparoscopic operations. Instrument articulation, downscaling of movements, absence of tremor, 3-D image, and comfort for the surgeon, assistant and scrub nurse are all new to the practice of laparoscopy. In our hands, robotic operative times for simple and radical hysterectomy are shorter than those obtained by conventional laparoscopy. Robotic technology is preferable to conventional laparoscopic instrumentation for the surgical treatment of gynecologic malignancies and most operations for benign disease of certain complexity such as hysterectomy myomectomy, and invasive pelvic endometriosis.

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Surg Technol Int. 2007;16:137-41.
Laparoscopic treatment of bowel endometriosis.
Lewis LA, Nezhat C.
Center for Special Minimally Invasive Surgery, Stanford University Medical Center, Palo Alto, California, USA.

The most common site of extragenital endometriosis is the intestinal tract, which accounts for approximately 80% of all extragenital endometriosis. The symptoms of intestinal endometriosis are crampy pain, flatulence, painful tenesmus, hyper-peristalsis, progressive constipation, diarrhea alternating with constipation, and occasionally rectal bleeding. As endometriosis in this location often undergoes fibrotic changes, it can be resistant to hormonal therapy, which makes surgical therapy the only option for many women. Until recently, laparoscopic treatment of bowel endometriosis was thought to be impossible. Development of several safe and effective techniques for laparoscopic treatment of intestinal endometriosis has made such treatment possible. In this chapter, the authors describe five proven techniques for treatment of intestinal endometriosis: shaving, disk excision, anterior rectal wall excision, segmental resection, and appendectomy.

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Fertil Steril. 2007 Apr 13; [Epub ahead of print]
Hormonal suppression treatment or dietary therapy versus placebo in the control of painful symptoms after conservative surgery for endometriosis stage III-IV. A randomized comparative trial.
Sesti F, Pietropolli A, Capozzolo T, Broccoli P, Pierangeli S, Bollea MR, Piccione E.
Endometriosis Center, Section of Gynecology & Obstetrics, Department of Surgery.

OBJECTIVE: To evaluate the effectiveness for the outcomes of endometriosis-related pain and quality of life of conservative surgery plus placebo compared with conservative surgery plus hormonal suppression treatment or dietary therapy. DESIGN: Randomized comparative trial. SETTING: University hospital. PATIENT(S): Two hundred twenty-two consecutive women who underwent conservative pelvic surgery for symptomatic endometriosis stage III-IV (r-AFS). INTERVENTION(S): Six months of placebo (n = 110) versus GnRH-a (tryptorelin or leuprorelin, 3.75 mg every 28 days) (n = 39) or continuous estroprogestin (ethynilestradiol, 0.03 mg plus gestoden, 0.75 mg) (n = 38) versus dietary therapy (vitamins, minerals salts, lactic ferments, fish oil) (n = 35). MAIN OUTCOME MEASURE(S): Painful symptoms (visual analogue scale score) and quality-of-life endometriosis-related symptoms (SF-36 score) at 12 months' follow-up. RESULT(S): Patients treated with postoperative hormonal suppression therapy showed less visual analogue scale scores for dysmenorrhoea than patients of the other groups. Hormonal suppression therapy and dietary supplementation were equally effective in reducing nonmenstrual pelvic pain. Surgery plus placebo showed significative decrease in dyspareunia scores. Postoperative medical and dietary therapy allowed a better quality of life than placebo. CONCLUSION(S): Postoperative hormonal suppression treatment or dietary therapy are more effective than surgery plus placebo to obtain relief of pain associated with endometriosis stage III-IV and improvement of quality of life.

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Fertil Steril. 2007 Feb 9; [Epub ahead of print]
Treatment utilization for endometriosis symptoms: a cross-sectional survey study of lifetime experience.
Sinaii N, Cleary SD, Younes N, Ballweg ML, Stratton P.
Reproductive Biology and Medicine Branch, National Institute of Child and Human Development, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology and Biostatistics, School of Public Health and Health Services, The George Washington University, Washington, DC.

OBJECTIVE: To examine the lifetime utilization and perceived benefit of medical treatments and surgical procedures for endometriosis-related symptoms. DESIGN: Cross-sectional study of self-reported survey data. SETTING: Academic research setting. PATIENT(S): Self-reported surgically diagnosed endometriosis by 1,160 women responding to the 1998 Endometriosis Association survey. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Use, perceived helpfulness, and outcomes of medical treatments and surgical procedures. RESULT(S): Ninety-five percent of respondents reported pelvic pain, had endured symptoms on average of 16 years, and were young (mean: 36 years), white, and educated. Many women (46%) had tried three or more medical treatments, and almost 20% took them for 10+ years. Many reported medical treatments as helpful for symptoms (range, 36.4%-61.9%), but some reported stopping because of ineffectiveness (range, 15.6%-26.1%) or side effects (range, 10.0%-43.5%). Danazol or medroxyprogesterone acetate (MPA) was most commonly stopped because of side effects (range, 40.7%-43.5%). Surgical procedures were performed at least three times on 42%. Nearly 20% had a hysterectomy or oophorectomy; these procedures were reported as most successful in improving symptoms (45.9% and 37.8%, respectively). CONCLUSION(S): Despite reporting various treatments as helpful, women used many different types and endured symptoms for an average of almost two decades, indicating the profound effect of endometriosis on women's health.

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J Gynecol Obstet Biol Reprod (Paris). 2007 Feb 1; [Epub ahead of print]
[Extragenital endometriosis.]
[Article in French]
Nisolle M, Pasleau F, Foidart JM.
Service de gynecologie-obstetrique, universite de Liege, CHU, hopital de la Citadelle, 1, boulevard du 12(e) de Ligne, 4000 Liege, Belgique.

Parietal, appendiceal, pleuropulmonary and diaphragmatic endometriosis represent 5% of endometriosis cases. Diagnosis and management of these extra-genital localisations are described according to the literature. Parietal endometriosis usually requires large resection of the tumor. Appendiceal endometriosis is frequently observed in cases of digestive endometriosis. Induration or rigidity of the appendix due to the presence of deep infiltrating endometriosis justifies appendicectomy. Thoracic and diaphragmatic endometriosis is characterized by the presence of typical symptoms during the perimenstrual periode. Medical treatment obtaining therapeutic amenorrhea is firstly administered and surgery is indicated in cases of symptoms recurrence.

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J Gynecol Obstet Biol Reprod (Paris). 2007 Feb 1; [Epub ahead of print]
[Guidelines for the management of painful endometriosis.]
[Article in French]
Roman H.
Clinique gynecologique et obstetricale, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France.

OBJECTIVES: To establish guidelines for the medical and surgical management of painful endometriosis. MATERIAL AND METHODS: An exhaustive review on Medline and Cochrane Database between 1980 and 2006 was performed. RESULTS: GnRH agonists, progestins, continuous monophasic oral contraceptives and danazol have a suppressive effect on dysmenorrhoea, nonmenstrual pain and dyspareunia (grade A). Surgical treatment is effective in painful endometriosis (grade B). Complete surgical excision of deep endometriotic lesions with conservation of uterus and ovaries has a limited term efficacy on pain relief (grade C). A multidisciplinary approach is recommended (grade C). The use of the psychotherapy improves the management of chronic pain (grade A). There is a lack of information concerning the therapeutic strategy able to prevent recurrences. Whether endometriosis recurrences occur, medical treatment should be the first line approach (expert opinion). A hysterectomy with salpingo-oophorectomy and complete excision of the lesions is efficient in women with pain recurrence who no longer desire pregnancy (grade C). CONCLUSION: Medical and surgical treatments have a limited term efficacy on painful endometriosis (grade A). The benefit/risk relationship, depending on secondary effect therapy, should be assessed on a case to case basis.

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J Gynecol Obstet Biol Reprod (Paris). 2007 Feb 1; [Epub ahead of print]
[Management of endometriosis: clinical and biological assessment.]
[Article in French]
Panel P, Renouvel F.
Service de gynecologie-obstetrique, centre hospitalier de Versailles, hopital Andre-Mignot, 177, rue de Versailles, 78157 Le Chesnay, France.

No symptom is pathognomonic for endometriosis. Main symptoms are pain (chronic pelvic pain, dysmenorrhea, deep dyspareunia, pain on defecation, cyclic pain) and infertility (grade C). There is no relation between rAFS endometriosis classification and symptoms intensity and frequency (grade B). Endometriosic lesions location and symptoms type are related to each other as well as symptoms intensity and lesions deepness or adhesion numbers (grade B). Clinical evidence is the same for infertile endometriosic women (grade C). Screening for depression is required among patients suffering from chronic endometriosic pelvic pain (grade C). Clinical examination includes: 1) retrocervix area inspection as well as upper part of posterior vaginal wall in search for typical bluish lesions (grade B); 2) vaginal examination in search for: a) uterosacral ligaments nodules (grade B); b) pain in uterosacral ligaments extension (grade B); 3) re-examination during menstruation increases its performance (grade B). No biological check-up in endometriosis diagnosis is necessary (grade A). CA 125 increase is related to: endometriomas and deep lesions volume (grade B), surgically treated infertile women prognosis (grade B). Presurgical endometriosis diagnosis is bettered by using diagnosis pattern in selected population (grade B). Rating scales are recommended in diagnosis and therapeutic follow up (grade B). Quality of life scales are useful to evaluate therapeutic efficiency (grade B).

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J Gynecol Obstet Biol Reprod (Paris). 2007 Jan 29; [Epub ahead of print]
[Surgical management of endometriosis.]
[Article in French]
Golfier F, Sabra M.
Service de chirurgie gynecologique et cancerologie, centre hospitalier Lyon sud, 69495 Pierre-Benite, France; Service de gynecologie obstetrique, Hotel-Dieu, 61, quai Jules-Courmont, 69002 Lyon, France.

Both laparoscopic techniques (excision and ablation) for the treatment of superficial peritoneal endometriosis are equally effective (EL2). For the treatment of ovarian endometriomas larger than 3 cm, laparoscopic cystectomy is superior to drainage and coagulation (EL1). Excision of deep rectovaginal endometriosis with or without rectal invasion significantly reduces endometriosis-associated pain (EL4). Laparoscopic partial bladder cystectomy is easier for dome endometriosis than vesical base lesions (EL4). Hysterectomy with ovarian conservation is associated with a high risk of pain recurrence (EL4). Despite bilateral oophorectomy, pain recurrence can occur with hormonal treatment (EL2). Rates of major (ureteral, vesical, intestinal or vascular) complications of endometriosis surgery range from 0.1 to 15% of patients. Higher rates are more common with deep endometriosis surgery (EL2). Patients should be aware of these specific major complications. It is advisable to explain that pain improves, either partially or completely, in about 80% of patients.

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J Gynecol Obstet Biol Reprod (Paris). 2007 Jan 29; [Epub ahead of print]
[Endometriosis related infertility.]
[Article in French]
Pouly JL, Canis M, Velemir L, Brugnon F, Rabischong B, Botchorichvili R, Jardon K, Peikrishvili R, Mage G, Janny L.
Departement de gynecologie-obstetrique et de reproduction humaine, polyclinique Hotel-Dieu, CHU de Clermont-Ferrand, BP 69, 63003 Clermont-Ferrand, France.

From the literature, the crucial knowledge were drawn among endometriosis related infertility. Endometriosis is an important factor of infertility in minimal or light stages and a major one in mild or moderate stages. Thus, a laparoscopy must be performed to confirm endometriosis when suggestive clinical or biological signs exist. In absence of them, laparoscopy can be delayed after intra-uterine inseminations (IUI). The first line treatment is laparoscopic surgery. Its efficacy is proven. It is useless to prescribe a post-operative medical treatment (GnRH analogues). Surgery leads to 25 to 40% of deliveries. It is dependant on age, infertility duration, tubo-ovarian adhesion and tubes involvement. But, surgery can be avoided and the patient is directly referred to In Vitro Fertilization (IVF) when the lesions extension is so important that surgery exposes to complications or when there is a permanent other indication for IVF (severe male infertility). When infertility persists 6 to 12 months after surgery and without patent recurrence, ovulation stimulations and IUI are performed as the second line treatment. After IUI failure, or in case of recurrence, IVF must be applied. A second surgery is not recommended. The IVF results are not impaired by the presence of endometriosis and even of endometriomas. Thus, it is useless to operate again endometriosis before IVF. In opposition, in severe stages or in cases of recurrence, a pre-IVF medical treatment (GnRH analogues) improves the results. IVF do not increased the risk of endometriosis acute growth. In case of infertility and pain, infertility is considered as the first target. But medical treatment can be prescribed between the IVF attempts.

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Can Fam Physician. 2006 Dec;52(12):1556-62.
Below the belt: approach to chronic pelvic pain.
Bordman R, Jackson B.
Benign Uterine Conditions Project, Centre for Effective Practice, Department of Family and Community Medicine, University of Toronto, Ontario, Canada. rbordman@rogers.com

OBJECTIVE: To present a practical approach to the symptom complex called chronic pelvic pain (CPP). Chronic pelvic pain is defined as nonmenstrual pain lasting 6 months or more that is severe enough to cause functional disability or require medical or surgical treatment. SOURCES OF INFORMATION: MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched from January 1996 to December 2004. MAIN MESSAGE: While the source of pain in CPP can be gynecologic, urologic, gastrointestinal, musculoskeletal, or psychoneurologic, 4 conditions account for most CPP: endometriosis, adhesions, interstitial cystitis, and irritable bowel syndrome. More than one source of pain can be found in the same patient. Management involves treating the underlying condition, the pain itself, or both. Nonnarcotic analgesics are first-line therapy for pain relief; hormonal therapies are beneficial if the pain has a cyclical component. A multidisciplinary approach addressing environmental factors and incorporating medical management with physiotherapy, psychotherapy, and dietary modifications works best. CONCLUSION: Although caring for patients with CPP can be challenging and frustrating, family physicians are in an ideal position to manage and coordinate their care.

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Eur J Obstet Gynecol Reprod Biol. 2006 Dec 16; [Epub ahead of print]
A randomized study comparing triptorelin or expectant management following conservative laparoscopic surgery for symptomatic stage III-IV endometriosis.
Loverro G, Carriero C, Rossi AC, Putignano G, Nicolardi V, Selvaggi L.
Department of Gynecology, Obstetrics, and Neonatology, University of Bari, Italy.

OBJECTIVE: To investigate the role of adjuvant treatment with gonadotropin-releasing-hormone agonist (GnRHa) following conservative surgical treatment of endometriosis. STUDY DESIGN: Sixty patients in the reproductive age (mean age 28.6 years), with symptomatic stages III and IV endometriosis following laparoscopic surgery and without previous hormonal treatment were enrolled in a prospective, randomized, controlled trial to compare the effects of 3-month treatment with triptorelin depot-3.75 i.m. (30 patients) versus expectant management using placebo injection (30 patients). RESULTS: Six patients (one in triptorelin group and five in placebo group) were lost at follow-up, the remaining 54 were suitable for analysis. Pelvic pain persistence or recurrence, endometrioma relapses and pregnancy rate were evaluated during a 5-year follow-up. The results of 29 cases treated with triptorelin and 25 that received placebo did not show significant differences in pain recurrence (P=1, RR=0.94, 95% CI=0.57-1.55), endometrioma relapse (P=0.67, RR=1.29, 95% CI=0.66-2.50), and pregnancy rate in infertile women (P=0.80, RR=0.81, 95% CI=0.37-1.80). Curves of time of pain recurrence and pregnancy during 5-year follow-up did not show significant differences between the two groups (P=0.79 and P=0.51, respectively, using Mantel-Haenzsel logrank test). CONCLUSION: Triptorelin treatment after operative laparoscopy for stage III/IV endometriosis does not appear to be superior to expectant management in terms of prevention of symptoms recurrence and endometrioma relapse, and has no influence on pregnancy rate in endometriosis-associated infertility.

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Can Fam Physician. 2006 Nov;52(11):1420-4.
Managing the misplaced: approach to endometriosis.
Jackson B, Telner DE.
University of Ottawa, Ottawa, Ontario, Canada. deanna.telner@utoronto.ca

OBJECTIVE: To review the presentation of endometriosis, steps to diagnosis, and medical and surgical management options. SOURCES OF INFORMATION: MEDLINE was searched from January 1996 to November 2004, EMBASE from January 1996 to January 2005, and the Cochrane Database of Systematic Reviews for the 4th quarter of 2004. MAIN MESSAGE: Endometriosis is a common, progressive disease with an estimated prevalence of 10%. It can cause dyspareunia, dysmenorrhea, low back pain, and infertility. It can be diagnosed on clinical grounds and treated without laparoscopy provided pregnancy is not desired. First- and second-line medical treatments are nonsteroidal anti-inflammatory drugs, combined oral contraceptive pills, progestins, gonadotropin-releasing hormone agonists, and androgens. Surgical options should be considered when these medications are ineffective or if pregnancy is desired. CONCLUSION: Family physicians have an important role in diagnosing and treating women with endometriosis.
 

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