Endometriosis Research: 2002-2006
     
Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005072.
Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery.
Abou-Setta AM, Al-Inany HG, Farquhar CM.
The Egyptian IVF-ET Center, Biostatistics & Information Technology, 3, Street 161, Hadayek El Maadi, Cairo, Egypt. abousetta_md@hotmail.com

BACKGROUND: Various options exist for treating endometriosis, including ovarian suppression therapy, surgical treatment or a combination of these strategies. Surgical treatment of endometriosis sets out to remove visible areas of endometriosis and restore anatomy by division of adhesions. The aim of medical therapy is to inhibit growth of endometriotic implants by suppression of ovarian steroids and induction of a hypo-estrogenic state. Postoperative treatment with a hormone-releasing intrauterine system, using levonorgestrel (LNG-IUS), has been suggested. OBJECTIVES: To determine if postoperative use of an LNG-IUS in women with endometriosis improves pain symptoms associated with menstruation and reduces recurrence compared with treatment with surgery only, placebo or systemic hormones. SEARCH STRATEGY: The following databases were searched: (1) Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials; (2) Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 1); (3) MEDLINE (1966 to January 2006) and EMBASE (1980 to January 2006); (4) National Research Register (NRR). (5) The citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies were also searched. SELECTION CRITERIA: Trials were included if they compared women undergoing any type of surgical treatment for endometriosis with uterine preservation then randomized to LNG-IUS insertion within two to three months versus no treatment, placebo (inert IUD) or systemic treatment. Diagnostic laparoscopy alone was excluded. DATA COLLECTION AND ANALYSIS: Two review authors (AM Abou-Setta and HG Al-Inany) independently selected studies for inclusion and extracted data. Statistical analysis was performed in accordance with the statistical guidelines developed by the Cochrane Menstrual Disorders and Subfertility Group. Data extracted from the trials was analyzed on an intention-to-treat basis. For binary data, the overall common odds ratio (OR) (that is, the odds of having clinical symptoms) and the risk difference with 95% confidence interval (CI) were calculated using the Mantel-Haenszel fixed-effect method. MAIN RESULTS: In one small randomized controlled trial (RCT) there was a statistically significant reduction in the recurrence of painful periods in the LNG-IUS group compared with the control group receiving a gonadotrophin-releasing hormone (GnRH) agonist (OR 0.14, 95% CI = 0.02 to 0.75). The proportion of women who were satisfied with their treatment was higher in the LNG-IUS group than in the control group but this difference did not reach statistical difference (OR 3.00, 0.79 to 11.44). AUTHORS' CONCLUSIONS: One small study has shown that postoperative use of the LNG-IUS reduces the recurrence of painful periods in women who have had surgery for endometriosis. There is a need for further well-designed RCTs of this approach.

-----

Expert Opin Pharmacother. 2006 Oct;7(15):2155-68.
Cetrorelix in the treatment of female infertility and endometriosis.
Finas D, Hornung D, Diedrich K, Schultze-Mosgau A.
Department of Andrology and the Out-Patient Clinic, Department of Obstetrics and Gynaecology, University Clinic of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany. finas.d@arcor.de

The use of cetrorelix within ovarian-stimulation protocols demonstrates several advantages compared with gonadotropin-releasing hormone (GnRH) agonist-containing protocols, which include, for example, significantly less time for analogue treatment and a reduction in the amount of gonadotropins needed. Furthermore, fewer side effects can be expected. There is no difference regarding endometrium quality and hormone profiles, and the results of assisted reproduction cycles are comparable. Cetrorelix also seems to be useful in the treatment of endometriosis which, in most cases, is an estrogen-dependent disease. Furthermore, fewer side effects occur with this agent (e.g., postmenopausal symptoms) and no estradiol add-back is needed. In the future, new nonpeptic GnRH antagonists are expected to be available for oral administration. Although they are still under investigation, these agents have the potential to improve patients' comfort and compliance.

-----

Minerva Ginecol. 2006 Oct;58(5):347-60.
Endoscopic management of endometriosis.
Chen CC, Falcone T.
Cleveland Clinic, Cleveland, OH, USA.

Randomized clinical trials in the effectiveness of laparoscopic surgery in the management of endometriosis associated with chronic pelvic pain show a 66% to 80% response rate. There is a 20% to 30% ''placebo'' response rate. The value of surgery for infertile patients with minimal and mild disease is still debated but is most likely small. In advanced disease, surgery clearly improves outcome, although the surgery is more challenging. After an initial unsuccessful surgery for restoration of fertility in patients with advanced endometriosis, in vitro fertilization rather than repeat surgery is more effective. Laparoscopic treatment of endometriomas should be performed by excisional surgery. Drainage and/or medical therapy is associated with a very high recurrence rate. The main concern with excision of endometriomas is the potential to decrease ovarian reserve. Most experts would agree that if there is an endometrioma of 4 cm or greater that a laparoscopic excision be performed before an anticipated in vitro fertilization cycle to decrease the potential risk of infection and improve access to follicle. Surgery for pelvic extragenital disease is challenging. Excision of rectal endometriosis may require disc excision of the nodular lesion or segmental resection. Morbidity of a laparoscopic procedure is similar to laparotomy. Relief of symptoms after laparoscopic bowel surgery is excellent but there are potential complications such as rectovaginal fistula and pelvic abscess. Endo-metriosis of the bladder or ureter typically only involves the overlying peritoneum and can be easily excised by laparoscopy. Excision of deeper lesions of the bladder and ureter require resection. This can be accomplished laparoscopically but requires experience with laparoscopic suturing.

-----

Climacteric. 2006 Oct;9(5):325-35.
Hormone replacement therapy in women with past history of endometriosis.
Soliman NF, Hillard TC.
Yeovil Hospital, Higher Kingston, Yeovil, UK.

Endometriosis is a common clinical condition and its treatment will often lead to an estrogen deficiency status. As most of these patients are young, they will need to consider hormone replacement therapy. Endometriosis is a hormone-dependent disease and estrogen replacement can be associated with a risk of recurrence or malignant transformation. Only a few studies have addressed this problem. With the use of hormone replacement therapy (HRT), there is an increased, although undefined, risk of recurrence of endometriosis, especially in known severe cases and in obese patients. Unopposed estrogen appears to carry a higher risk than combined preparations. Delay in starting HRT after pelvic clearance is not of any benefit. After radical surgery for severe endometriosis, women often have much to gain from HRT, particularly in the early years. Benefits of HRT in terms of control of menopausal symptoms, prevention of urogenital atrophy and loss of libido and bone protection are of particular importance. HRT may still have a role in prevention of cardiovascular disease in early menopause, but this remains unproven. Although there is no firm evidence, continuous combined preparations or tibolone would appear to be the optimum choice.

-----

J Minim Invasive Gynecol. 2006 Sep-Oct;13(5):442-6.
Laparoscopic resection of intestinal endometriosis: a 5-year experience.
Ribeiro PA, Rodrigues FC, Kehdi IP, Rossini L, Abdalla HS, Donadio N, Aoki T.
OG/Gyn Department, Santa Casa Medical School, Sao Paulo, Brazil. payroza@uol.com.br

STUDY OBJECTIVE: To describe the clinical manifestations, surgical techniques, and complications observed in patients undergoing laparoscopic resection of intestinal deeply infiltrating endometriosis (DIE). DESIGN: Prospective nonrandomized (Canadian Task Force Classification II-3). SETTING: University hospital and private practice. PATIENTS: We evaluated 125 patients with intestinal DIE treated from February 2000 through September 2005. INTERVENTIONS: Laparoscopic radical excision of DIE followed by resection of the rectosigmoid colon. MEASUREMENTS AND MAIN RESULTS: The clinical examination of our patients demonstrated that 66.4% of patients had tenderness, whereas 80.8% had nodules on the pouch of Douglas. In 95.2% we observed pain caused by cervical mobilization, and all the patients had pain during the pouch of Douglas mobilization. Regarding bowel infiltration, preoperative investigation with rectal endoscopic ultrasonography was positive in all cases. Endoscopic rectal ultrasonography demonstrated the depth of intestinal infiltration. Superficial lesions were observed in 9.6% of patients and muscularis involvement in 71.2%. The segmental resection was performed in most of the patients (92%) and the linear resection in 6.4% of them. Median surgical time was 110 minutes, and the median hospital stay was 7 days after the surgery; the patients continued fasting for 3 to 7 days. The return to normal activity was achieved in a median 15 days after the surgery. The surgical procedure and the postoperative follow-up demonstrated no complications in 90.4% of the patients. Minor complications were observed in 4% of the cases. Major complications occurred in 5.6% of the patients, including 2 cases of intestinal fistulas (1.6%) and 3 cases of long-lasting urinary retention (2.4%). CONCLUSION: Clinical symptoms of patients with intestinal endometriosis are not specific. Operative laparoscopy is a safe and effective method to treat intestinal endometriosis. To avoid major complications, special attention must be paid to the intestinal anastomosis and to the nerve preservation.

-----

Gynecol Obstet Fertil. 2006 Sep;34(9):727-34. Epub 2006 Sep 6.
[Endometriosis in teenagers]
[Article in French]
Bourdel N, Matsusaki S, Roman H, Lenglet Y, Botchorischvili R, Mage G, Canis M.
Service de gynecologie-obstetrique, polyclinique Hotel-Dieu, CHU de Clermont-Ferrand, boulevard Leon-Malfreyt, 63003 Clermont-Ferrand, France.

Endometriosis has long been considered as a disease of women over 30 years old. However, recent data from the literature demonstrated its high incidence in teenagers. Endometriosis in teenagers is generally associated with chronic pelvic pains and cyclical signs are less common than in adults. The persistence of the pain despite an estroprogestative contraception associated with non-steroidal anti-inflammatory drugs is a strong argument for the diagnosis and justifies a laparoscopic exploration. During this laparoscopy, the search for atypical lesions, which are much more common than typical ones, is essential. Biopsies of these lesions is mandatory in every patient to rule out false positives and false negatives which are common in atypical lesions. The aim of the treatment is to improve the pain. The first line of medical treatment is based on the estroprogestative contraception and non-steroidal anti-inflammatory drugs. The prescription of GnRH should be the ultimate solution because the bone reserve increases until the age of 18 to 20. The laparoscopic treatment, when required, should be as complete as possible. Early diagnosis and medical management may prevent the development of the disease. However, further studies in the teenager are essential to improve the current empirical management.

-----

Am Fam Physician. 2006 Aug 15;74(4):594-600.
Diagnosis and management of endometriosis.
Mounsey AL, Wilgus A, Slawson DC.
Dept. of Family Medicine, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA.
Free full text at: http://www.aafp.org/afp/20060815/594.html

Signs and symptoms of endometriosis are nonspecific, and an acceptably accurate noninvasive diagnostic test has yet to be reported. Serum markers do not provide adequate diagnostic accuracy. The preferred method for diagnosis of endometriosis is surgical visual inspection of pelvic organs with histologic confirmation. Such diagnosis requires an experienced surgeon because the varied appearance of the disease allows less-obvious lesions to be overlooked. Empiric use of nonsteroidal anti-inflammatory drugs or acetaminophen is a reasonable symptomatic treatment, but the effectiveness of these agents has not been well-studied. Oral contraceptive pills, medroxyprogesterone acetate, and intrauterine levonorgestrel are relatively effective for pain relief. Danazol and various gonadotropin-releasing hormone analogues also are effective but may have significant side effects. There is limited evidence that surgical ablation of endometriotic deposits may decrease pain and increase fertility rates in women with endometriosis. Presacral neurectomy is particularly beneficial in women with midline pelvic pain. Hysterectomy and bilateral salpingo-oophorectomy definitively treat pain from endometriosis at 10 years in 90 percent of patients.

-----

Acta Chir Belg. 2006 Jul-Aug;106(4):413-6.
Surgery for gastrointestinal endometriosis: indications and results.
Houtmeyers P, Ceelen W, Gillardin JM, Dhondt M, Pattyn P.
Departments of Surgery, Ghent University Hospital, Ghent, Belgium.

BACKGROUND: Although gastrointestinal endometriosis is an uncommon and often unexpected finding, the best treatment requires removal of all endometriotic lesions. The purpose of our study was to report our experience with the diagnosis and treatment of bowel endometriosis. MATERIAL AND METHODS: From January 1997 to January 2004, 13 patients (mean 35.7y ; range 21-55y) were operated for bowel endometriosis. We noted: age, history of endometriosis, previous pregnancies, preoperative investigations and symptoms, operative procedure and intraoperative findings. Follow-up varied between one month postoperative examination and seven years. RESULTS: Presenting symptoms of the cases were: acute appendicitis (3), dysmenorrhoea (7), constipation (6), pelvic pain (2), rectal bleeding (3) and dyspareunia (2). Operative management was performed in accordance with the anatomical distribution. Seven patients had a history of previous operations and multifocal involvement was present in 61.5% of cases. At a median follow-up of 12.2 months, 83.3% had complete relief of their initial complaints, with only one reoperation needed. The pregnancy rate after surgery was 66.6%. Preoperative tests were: ultrasound for ovarian endometriomas, coloscopy, barium enema, vaginal palpation for detecting rectovaginal involvement, MRI and CT scan. These tests predicted the extension of endometriotic process correctly in 50% of the cases. CONCLUSIONS: Endometriosis of the sigmoid and rectum is rare but can give rise to severe gastrointestinal and pelvic symptoms. Preoperative investigations are not infallible in predicting the extent of the disease, sometimes placing the surgeon before a dilemma, because it involves mostly young women in the reproductive phase of life. The colorectal surgeon, therefore, should seek the advice of an experienced gynaecologist and vice versa. Removal of all endometriotic lesions is mandatory for obtaining an optimal relief of symptoms.

-----

J Minim Invasive Gynecol. 2006 Jul-Aug;13(4):281-8.
Recurrence of endometriomas after laparoscopic removal: Sonographic and clinical follow-up and indication for second surgery.
Exacoustos C, Zupi E, Amadio A, Amoroso C, Szabolcs B, Romanini ME, Arduini D.
Obstetrics and Gynecology Department, Universita degli Studi di Roma "Tor Vergata," Rome, Italy.

STUDY OBJECTIVE: This study involved patients who, after laparoscopic surgery, had recurrence of endometriomas detected by sonography. The aim of this study was to evaluate the role of transvaginal sonography (TVS) in the management of recurrent endometriomas and to establish ultrasonographic criteria that would direct the therapy toward additional surgery versus medical or expectant management. DESIGN: Retrospective analysis of 62 reproductive-age women who showed recurrence of endometriomas on TVS after laparoscopic removal of an ovarian endometrioma by the stripping technique (Canadian Task Force classification II-1). SETTING: Obstetrics and Gynecology Department, University of Rome Tor Vergata. PATIENTS: Sixty-two patients with recurrent endometriomas after first-line treatment with laparoscopy. INTERVENTIONS: Ultrasonographic follow-up and/or second surgery. MEASUREMENTS AND MAIN RESULTS: Recurrence of an ovarian endometrioma was defined as the presence of ovarian cysts with the typical sonographic criteria of endometriomas and a diameter of more than 10 mm. The clinical and sonographic postoperative follow-up period lasted from 6 to 97 months (median 24.6) after the first procedure. Of 62 patients with recurrent endometriomas, 50 had recurrence on the treated ovary, 7 on the contralateral untreated ovary, and 5 on both the treated and untreated ovaries. Recurrence of endometriomas was associated with symptoms (pain or infertility) in 47 patients (76%), while the remaining 15 (24%) were asymptomatic. Of the 47 symptomatic patients with recurrence detected by TVS, a second procedure was performed in 15. Second surgery in these patients was indicated by the larger size of the recurrent cysts, a poor response to medical treatment, the presence on TVS of pelvic adhesions and nodules of deep endometriosis, and overall progression of the disease. Symptomatic patients who did not undergo a second procedure (32) had smaller recurrent endometriomas. However of the 31 symptomatic patients with large recurrent endometriomas (>3 cm), only 45% had repeat surgery. CONCLUSION: Recurrent endometriomas, as detected by TVS, can remain asymptomatic and do not necessarily progress in size with or without medical treatment. The decision to reoperate depends less on the endometrioma's size than on symptoms, in particular severe pain, and failure of medical treatment. However such patients are also more likely to have signs of deep nodules and adnexal/bowel adhesions and larger endometriomas on TVS scan, thus predisposing them to require a second procedure.

-----

Gynecol Obstet Fertil. 2006 Jul 3; [Epub ahead of print]
[Laparoscopic surgery of deep endometriosis. About 118 cases.]
[Article in French]
Panel P, Chis C, Gaudin S, Letohic A, Raynal P, Mikhayelyan M, Fraleu B, Sangana G, Almeras C, Dufour C, Boidart F.
Service de gynecologie-obstetrique, hopital Andre-Mignot, centre hospitalier de Versailles, 177, rue de Versailles, 78157 Le Chesnay cedex, France.

OBJECTIVE: To evaluate risks and benefits of laparoscopic surgery of deep endometriosis, especially with bowel involvement with the aim of improve the inform consent of patients and choice of adequate management. PATIENTS AND METHODS: Observational continuous study on 118 patients suffering from deep endometriosis (48 with bowel endometriosis) treated by laparoscopic surgery. RESULTS: 95.6% of the patients improved their symptoms (93.7% for dyspareunia). Upon the 29 infertile patients, 21 (72%) got pregnant, including 14 (66%) spontaneously. During operative time, 3 laparotomies occurred, two of them for haemorrhage. During postoperative time, 4 major complications (2 rectal fistulas and 2 ureteral necrosis) and minor complications occurred. DISCUSSION AND CONCLUSIONS: Those data confirm the efficiency of laparoscopic treatment of deep endometriosis especially for pain relief and fertility. Nevertheless, few but severe complications may occur. Therefore, it is imperative to deliver clear, loyal and appropriate information before to proceed to such a treatment.

-----

Arch Gynecol Obstet. 2006 Jul;274(4):203-5. Epub 2006 May 12.
Over one thousand patients with early stage endometriosis treated with the Helica Thermal Coagulator (HELICA): safety aspects.
Hill N, McQueen J, Morey R, Hanna L, Chandakas S, El-Toukhy T, Erian J.
Department of Obstetrics and Gynaecology, Princess Royal University Hospital, Farnborough Common, Kent, BR6 8ND, UK.

Study objective: To assess the safety of the Helica Thermal Coagulator in the laparoscopic treatment of early stage endometriosis. Design: Retrospective, observational. Settings: The Princess Royal University Hospital, The Sloane and Chelsfield Park Hospitals, Kent, UK. Patients: One thousand and sixty patients with early stage endometriosis. Results: All patients were treated laparoscopically with the Helica Thermal Coagulator; a new laparoscopic device that combines electrical energy with helium for the treatment of endometriosis. No major bladder, ureteric or bowel injuries occurred. The only complication was a perforated vagina from the cutting probe during dissection of the cul-de-sac in a patient with a vaginal endometriotic nodule. Conclusion: The Helica Thermal Coagulator is a safe device for the laparoscopic treatment of endometriosis.

-----

Fertil Steril. 2006 Jun 7; [Epub ahead of print]
Outcome of laparoscopic ureterolysis for ureteral endometriosis.
Ghezzi F, Cromi A, Bergamini V, Serati M, Sacco A, Mueller MD.
Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, VareseItaly.

OBJECTIVE: To evaluate the adequacy of laparoscopic ureterolysis as a primary treatment option for ureteral endometriosis. DESIGN: Prospective collaborative cohort study. SETTING: Gynecologic departments of three university hospitals. PATIENT(S): Women with ureteral endometriosis exhibiting moderate-to-severe hydronephrosis on preoperative intravenous pyelography. INTERVENTION(S): Laparoscopic ureterolysis. MAIN OUTCOME MEASURE(S): Cure rate, disesase recurrence. RESULT(S): Thirty-three patients underwent laparoscopic ureterolysis during the study period. Bilateral involvement of ureters was found in 4 (12.1%) cases. In women with unilateral lesions the left ureter was more frequently affected (24/29 vs. 5/29). Ureteral involvement was associated with uterosacral ligaments endometriosis in 65.5% (22/34) of cases. No inadvertent ureteral injuries occurred during ureterolysis. A partial wall resection of the ureter was necessary in one case and a segmental ureteral resection with vescicopsoas hitch was required in a women with intrinsic ureteral endometriosis. The median (range) follow-up time was 16 months (range: 3-53 months). Thirty-two patients (96.7%) had a patent ureter on the 3-month postoperative intravenous pyelography. The recurrence rate of ureteral lesions was 12.1% (4/33). CONCLUSION(S): Our findings suggest that a conservative laparoscopic approach is an effective treatment option in most patients with ureteral endometriosis exhibiting moderate-to-severe hydronephrosis.

-----

Fertil Steril. 2006 Jun 3; [Epub ahead of print]
Is the endometriosis recurrence rate increased after ovarian hyperstimulation?
D'Hooghe TM, Denys B, Spiessens C, Meuleman C, Debrock S.
Leuven University Fertility Center, Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Leuven, Belgium.

OBJECTIVE: To test the hypothesis that the cumulative endometriosis recurrence rate (CERR) after fertility surgery for endometriosis stage III or IV is increased in women exposed to very high E(2) levels during ovarian hyperstimulation (OH) for IVF when compared with women exposed to less high E(2) levels during OH for intrauterine insemination (IUI). DESIGN: Retrospective cohort study including infertility patients with endometriosis stage III or IV. SETTING: Leuven University Fertility Center, between 1990 and 2001. PATIENT(S): Patients (n = 67) with endometriosis stage III (n = 45) or IV (n = 22) who underwent pelvic reconstructive surgery and subsequently started fertility treatment with either IVF only (n = 39), both IVF and IUI in different cycles (n = 11), or IUI only (n = 17). INTERVENTION(S): Life table analysis was used to calculate the CERR. MAIN OUTCOME MEASURE(S): The CERR based on histologic or cytologic proof of disease recurrence. RESULT(S): At 21 months after the start of OH the overall CERR was 31% and was significantly lower in patients treated with IVF only (7%) or women treated with both IVF and IUI in different cycles (43 %) than in those treated with IUI only (70%). At 36 months after the start of OH, the overall CERR was 63%. CONCLUSION(S): In contrast to our hypothesis, the results from this study showed that the CERR is lower after ovarian hyperstimulation for IVF than after lower-dose ovarian stimulation for IUI, suggesting that temporary exposure to very high E(2) levels in women during OH for IVF is not a major risk factor for endometriosis recurrence in women treated with assisted reproductive technology.

-----

Acta Obstet Gynecol Scand. 2006;85(6):712-5.
Endoscopic treatment of deep infiltrating endometriosis (DIE) involving the bladder and rectosigmoid colon.
Langebrekke A, Istre O, Busund B, Johannessen HO, Qvigstad E.
Department of Gynaecology, Ulleval University Hospital, Oslo, Norway. anton.langebrekke@ulleval.no

BACKGROUND: To study the feasibility, complications and symptom relief of laparoscopic treatment in patients with deep infiltrating endometriosis. METHODS: From January 2004 to March 2005, 24 patients with deep infiltrating endometriosis were treated with laparoscopic techniques. Preoperative symptoms, staging, involvement of the disease, and surgical procedures were recorded. Operating time and perioperative complications were also registered, as well as follow-up of the patients. RESULTS: The surgical treatment was individualized with removal of deep infiltrating endometriosis in all 24 patients, additional bladder resection in five patients and colorectal resection in eight patients. In two cases laparoconversion was performed, and one patient had a temporary loop ileostomy. We observed no major peri- or postoperative complications. Median operating time was 3.4 h (range 1.4-8.0 h). All patients with bladder involvement were relieved of their urinary dysfunction, while all except three patients were successfully treated for their pain problems, and also these three patients had symptom relief. CONCLUSIONS: Patients with deep infiltrating endometriosis represent a challenge to surgical procedures. Our results show that radical laparoscopic surgery including colorectal and bladder resection is feasible, safe, and effective in almost all patients.

-----

S D Med. 2006 Apr;59(4):153-9.
A review of current management of endometriosis in 2006: an evidence-based approach.
Hansen KA, Eyster KM.
Department of Obstetrics and Gynecology, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA.

Endometriosis, a common cause of morbidity in reproductive age females, results in pelvic pain and infertility. Effective, evidence-based treatments of endometriosis-associated infertility include conservative surgical therapy and assisted reproductive technologies. In early stage endometriosis ovulation induction, with or without intrauterine insemination, improves pregnancy rates. In early stage disease in vitro fertilization reduces time to pregnancy as compared to controls, but does not increase the chance of pregnancy after three years. Endometriosis-associated pain can be approached with surgical or medical therapies. Conservative surgery maintains the reproductive organs and is an effective mode of treatment for endometriosis-associated pain. A more radical surgical approach of hysterectomy with bilateral salpingo-oophorectomy, not investigated in randomized controlled trials, remains a mainstay of therapy for endometriosis-associated pain in patients who have completed child-bearing. Current medical therapies rely upon interruption of normal cyclic, ovarian hormone production resulting in an environment not conducive to the growth of endometriosis. The current accepted therapies for endometriosis include danazol, progestational agents, oral contraceptive agents, and gonadotropin-releasing hormone analogues which all function similarly in relieving pain. The new era of genomics promises to help characterize endometriosis and allow one to tailor therapies based on a woman's symptoms and reproductive goals.

-----

JSLS. 2006 Jan-Mar;10(1):30-6.
The treatment of mild endometriosis with laser laparoscopy: a two-step treatment analysis of patients whose primary therapy was successful.
Paulson JD, Habli M, Alizade A, Borromeo R.
Institute for Advanced Endoscopic Training, Norfolk, Virginia, USA. endodoc11@aol.com

OBJECTIVES: The most advantageous treatment for pelvic endometriosis that is not extensive has long been the subject of debate. In recent years, the ability to detect atypical presentations has allowed the gynecological surgeon to treat this entity more readily. The treatment in the past has been concerned with the singular treatment being applied at the time, not on the prior treatment effects on current therapy. The purpose of the current study was to see whether previous successful treatment modalities affected the success of subsequent laparoscopic laser fulguration treatment of endometriosis. METHODS: Patients who were previously treated for their endometriosis (minimal and mild) and had success in achieving pregnancy were treated for their disease after failing to become pregnant after delivery. They were treated with laparoscopic laser fulguration of the disease and the results were examined by chi-square (chi2) analysis. RESULTS: There appears to be no difference in current pregnancy rates in patients who were successfully treated in the original treatment for endometriosis, no matter which of the therapies had been used. CONCLUSION: If endometriosis is diagnosed at the time of laparoscopy and is easily amenable to treatment, it should be treated at the time of surgery regardless of prior treatment and results.

-----

J Br Menopause Soc. 2006 Mar;12(1):28-33.
Managing women with a previous diagnosis of endometriosis.
Bain C.
Gynaecology Department, Aberdeen Royal Infirmary, Aberdeen, UK.

Endometriosis is an estrogen-dependent condition that primarily inflicts women of reproductive age. There are several gradations of the disease and its extent does not always signify its symptomatic presentation. In those women who have long suffered from endometriosis, previous treatments and their assumed success influence clinical decision making on the use of hormone replacement therapy after menopause. This review considers the management strategies for those women who have become prematurely menopausal after extensive surgical treatment for endometriosis.

-----

Hum Reprod. 2006 Mar;21(3):774-781. Epub 2006 Jan 31.
Laparoscopic nerve-sparing complete excision of deep endometriosis: is it feasible?
Landi S, Ceccaroni M, Perutelli A, Allodi C, Barbieri F, Fiaccavento A, Ruffo G, McVeigh E, Zanolla L, Minelli L.
Departments of Obstetrics and Gynecology and General Surgery, Ospedale Sacro Cuore, Via Don A.Sempreboni 5, 37024 Negrar (Verona), School of Medicine, University of Bologna, Italy, Nuffield Department of Obstetrics and Gynaecology, University of Oxford, UK and Department of Cardiology, University of Verona, Italy.

BACKGROUND: Little is known about the morbidity associated with laparoscopic complete excision of endometriosis in terms of urinary, digestive and sexual function. METHODS: We performed a prospective non-randomized study in 45 patients with laparoscopic complete excision of all detectable foci of endometriosis with segmental bowel resection using a non nerve-sparing technique (control group-group A n = 20) and a nerve-sparing technique (case group-group B n = 25). At initial gynaecological evaluation, and at follow-up details on dysmenorrhoea, pelvic pain, dyspareunia and dyschezia were evaluated using an interview-based questionnaire (10-point analogue rating scale: 0 = absent, 10 = unbearable). RESULTS: The mean (+/-SD) follow-up period was 15.3 +/- 10 months (range, 8.8-23 months) for group A and 3.5 +/- 2.1 months (range, 0.3-5.2 months) for group B. In the immediate postoperative course, in group A three women required blood transfusion vs seven women in group B (P = 0.003). The median time to resume the voiding function was significantly shorter in group B (12.5 vs 3.0 days; P < 0.01). At the time of follow-up a higher proportion of patients in group B were 'very satisfied' than those in group A (87.7% vs 59.0%, P = 0.013). CONCLUSIONS: Laparoscopic nerve-sparing complete excision of endometriosis seems to be feasible and offers good results in terms of bladder morbidity reduction with apparently higher satisfaction than classical technique. Larger series with longer follow-up are needed to confirm our results.

-----

Hum Reprod. 2006 Feb 22; [Epub ahead of print]
Laparoscopic excision of posterior vaginal fornix in the treatment of patients with deep endometriosis without rectum involvement: surgical treatment and long-term follow-up.
Angioni S, Peiretti M, Zirone M, Palomba M, Mais V, Gomel V, Melis GB.
Division of Gynecology, Obstetrics and Pathophysiology of Human Reproduction, Department of Surgery, Maternal-Fetal Medicine, and Imaging, University of Cagliari, Cagliari, Italy.

BACKGROUND: The objective of the study is to evaluate the short- and long-term efficacy of complete laparoscopic excision of deep endometriosis, without rectum involvement, with the opening and partial excision of the posterior vaginal fornix. METHODS: Thirty-one patients were included in the study with symptomatic extensive disease including involvement of the cul-de-sac, rectovaginal space and posterior vaginal fornix without rectum involvement. Endoscopic surgery was performed with complete separation of rectovaginal space and in-block resection of the diseased tissue, opening and partial excision of the posterior vaginal fornix and vaginal closure either by laparoscopic or by vaginal route. Patients filled in questionnaires on pain before and 12, 24, 36, 48 and 60 months after surgical treatment. RESULTS: No intraoperative complications were observed; 65% were free of analgesic on post-operative day 2, 38% had total remission of chronic pain and 22% were improved; 38% had total remission of dysmenorrhoea and 22% were improved; 45% had total remission of dyspareunia and 25% were improved. Follow-up improvement of symptoms was statistically significant and was maintained for 5 years without recurrence of the disease or repeated surgery (P < 0.001). CONCLUSION: Complete surgical resection of deep infiltrative endometriosis with excision of the adjacent tissue of the posterior vaginal fornix improves quality of life with persistence of results for long time in patients not responsive to medical treatment.

-----

Ann Thorac Surg. 2006 Feb;81(2):761-9.
Thoracic endometriosis: current knowledge.
Alifano M, Trisolini R, Cancellieri A, Regnard JF.
Department of Thoracic Surgery, Hotel-Dieu, AP-HP, Paris, France. marcoalifano@yahoo.com

Thoracic endometriosis syndrome includes four well-recognized clinical entities, namely catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis and lung nodules, as well as some exceptional presentations. The etiological mechanisms of this syndrome are not well understood, and different theories have been proposed. Controversies exist about optimal management, as experience has been drawn from case reports and small clinical series. Surgery, hormonal treatments and combined approaches have all been proposed, with variable results in terms of short and long term outcome.

-----

Gynecol Obstet Fertil. 2006 Jan;34(1):8-13. Epub 2006 Jan 6.
[Abdominal wall endometriosis after caesarean section: report of fifteen cases]
[Article in French]
Picod G, Boulanger L, Bounoua F, Leduc F, Duval G.
Service de chirurgie gynecologique, hopital Jeanne-de-Flandre, CHRU de Lille, avenue Avinee, 59037 Lille cedex, France. g.picod@caramail.com

OBJECTIVE: Parietal endometriosis is an uncommon pathology. It can occur on all the scars, most often after a surgical procedure with hysterotomy. Surgical scar endometriosis following caesarean section has an incidence of 0.03 to 0.4%. PATIENTS AND METHODS: This retrospective study reviewed all the cases of parietal endometriosis seen during a 7-year period in the department of visceral surgery of the Armentiere's hospital center. A pathological analysis has confirmed each lesion retained. RESULTS: 15 women were treated during this period. The mean age is 32 years. All the women have one or two antecedents of caesarean with Pfannenstiel's laparotomy. The interval between the caesarean and the appearance of the first symptoms is on average of 5 years and 11 months. Only 66.6% of cases presented the classical symptoms with cyclic pain. For 66.6% of patients, the diagnosis of parietal endometriosis was suspected before the treatment. The treatment is a surgical one with exeresis for all the women. In 13.3% of the cases, the lesion is pre aponeurotic. In 46.6% of the cases, it overgrows the rectus abdominis muscle, in 33.3% of the cases the external abdominal oblique and at last a lesion overgrows the transversus abdominis and one is in an inguinal localization. The mean size of lesions is 2.48 cm. We have not notified complications and no recurrence was noted. DISCUSSION AND CONCLUSION: The local endometrial cell transplant is the most likely mechanism to explain the physiopathology of parietal endometriosis. The classical symptoms associate a painful swelling and cyclic pain related to the menstrual period, but all of these symptoms are not always associated. The contribution to the diagnosis of the imaging studies is weak. The surgical treatment has to be sufficiently wide to avoid all recurrence. No means of prevention has proved its efficiency. In 26.6% of cases the parietal endometriosis is associated to pelvic endometriosis. This localization is more often asymptomatic. Then the realization of a laparoscopic exploration is not indicated immediately.

-----

Hum Reprod. 2006 Jan 26; [Epub ahead of print]
Quality of life after laparoscopic colorectal resection for endometriosis.
Dubernard G, Piketty M, Rouzier R, Houry S, Bazot M, Darai E.
Service de Gynecologie, Obstetrique et Medecine de la Reproduction, Hopital Tenon, Universite Saint-Antoine Paris VI, Assistance Publique des Hopitaux de Paris, France.

BACKGROUND: Indications of colorectal resection for endometriosis remain controversial because of the risk of major complications. Therefore, the aims of the current study were to evaluate the efficacy of laparoscopic segmental colorectal resection for endometriosis on quality of life and gynaecologic and digestive symptoms, and its complications. METHODS: After magnetic resonance imaging and rectal endoscopic sonographic evaluation of symptomatic colorectal endometriosis, 58 consecutive women requiring colorectal resection were included in this study. Symptom questionnaires and the short-form (SF)-36 Health Status and the quality of life score were completed. Linear intensity scores for several gynaecologic and digestive symptoms and perioperative complications were also recorded. RESULTS: Fifty-one women (88%) underwent laparoscopic segmental colorectal resection and seven required laparoconversion. Major complications occurred in nine cases (15.5%), including six rectovaginal fistulae (10.3%), and the three remaining complications corresponded to a haemoperitoneum, a uroperitoneum and a pelvic abscess. Median follow-up after colorectal resection was 22.5 months (2-55 months). A significant improvement in dysmenorrhoea (P < 0.0001), dysparaeunia (P < 0.0001), bowel movement pain or cramping (P < 0.0001), pain on defecation (P < 0.0001), diarrhoea (P < 0.016), lower back pain (P < 0.0001) and asthaenia (P < 0.0002) was observed. Tenesmus, rectorrhagia and constipation were not improved. All the items of the SF-36 Health Status and the quality of life score were improved after colorectal resection for endometriosis. CONCLUSION: Laparoscopic segmental colorectal resection for endometriosis significantly improves quality of life and gynaecologic and digestive symptoms. However, women have to be informed on the risk of complications including rectovaginal fistula.

-----

Gynecol Endocrinol. 2006 Jan;22(1):9-17.
High-dose pilot study with the novel progestogen dienogestin patients with endometriosis.
Schindler AE, Christensen B, Henkel A, Oettel M, Moore C.
Department of Gynecology and Obstetrics, University of Essen, Essen, Germany.

High-dose dienogest (20 mg/day) was used for the treatment of endometriosis in women aged 18-52 years after laparoscopic and histological diagnosis of endometriosis and staging according to the revised American Fertility Society criteria. Treatment efficacy was analyzed objectively by second-look laparoscopy, and serum hormone measurements and evaluation of endometriosis-related symptoms were performed done and side-effects recorded. Compared with other high-dose progestin therapies, treatment with dienogest was shown to be effective even in stage IV endometriosis. The side-effect profile of the high-dose dienogest treatment appears to be highly favorable compared with other treatments. Neither the menopausal symptoms caused by therapy with gonadotropin-releasing hormone agonists nor the adverse androgen-related effects induced by danazol were observed. Therefore, long-term high-dose dienogest therapy can be recommended particularly for women with progressive endometriosis.

-----

Eur J Obstet Gynecol Reprod Biol. 2005 Dec 22; [Epub ahead of print]
Reproductive outcome after laparoscopic treatment of minimal and mild endometriosis using Helica Thermal Coagulator.
Nardo LG, Moustafa M, Beynon DW.
Department of Obstetrics and Gynaecology, Frimley Park Hospital, Surrey, United Kingdom.

OBJECTIVE: To investigate the reproductive outcome following Helica Thermal Coagulator (Helica TC) in an infertile population with early-stage endometriosis. DESIGN: A clinical observational trial conducted in a NHS tertiary referral centre for treatment of endometriosis. Forty-four healthy infertile women (mean age 21 years, range 18-34 years) with laparoscopically confirmed diagnosis of minimal (stage I) or mild (stage II) endometriosis were included. All visible endometriotic lesions and adhesions were treated using Helica TC at the same time of diagnostic laparoscopy. Following laparoscopy, women attempted to conceive spontaneously and were followed for 12 months or until delivery. No hormonal therapy for endometriosis was given whatsoever. RESULTS: One woman was lost to follow-up and the remaining 43 women were considered in the final analysis. The cumulative pregnancy rate was 23.2% (10/43). All pregnancies occurred spontaneously and neither miscarriages nor ectopic pregnancies were observed. Pregnancy rate did not differ between women with stage I and those with stage II endometriosis. The time-to-pregnancy was similar in women with different stage endometriosis. No surgical complications were encountered. CONCLUSIONS: These findings suggest that Helica TC is a simple and safe conservative laparoscopic surgery for early-stage endometriosis. Helica TC appears to improve reproductive outcome in women with otherwise unexplained infertility. Large RCTs are needed to define these preliminary data.

-----

Fertil Steril. 2005 Dec;84(6):1574-8. Comment in: Fertil Steril. 2005 Dec;84(6):1579-80. Fertil Steril. 2005 Dec;84(6):1581. Fertil Steril. 2005 Dec;84(6):1582-4. Fertil Steril. 2005 Dec;84(6):1585-6. Fertil Steril. 2005 Dec;84(6):1587-8.
Role of laparoscopic treatment of endometriosis in patients with failed in vitro fertilization cycles.
Littman E, Giudice L, Lathi R, Berker B, Milki A, Nezhat C.
Department of Gynecology and Obstetrics, Stanford University Medical Center, Stanford, California, USA.

OBJECTIVE: To report our experience in patients with previous IVF failures who conceived after laparoscopic treatment of endometriosis. DESIGN: Retrospective case series. SETTING: Tertiary center IVF and endoscopy programs. PATIENT(S): Infertility patients with history of prior IVF failures. INTERVENTION(S): Laparoscopic evaluation and treatment of endometriosis by the same surgeon. MAIN OUTCOME MEASURE(S): Occurrence of conception after laparoscopic treatment of endometriosis. RESULT(S): Of 29 patients with prior IVF failures, 22 conceived after laparoscopic treatment of endometriosis, including 15 non-IVF pregnancies and 7 IVF pregnancies. CONCLUSION(S): In the absence of tubal occlusion or severe male factor infertility, laparoscopy may still be considered for the treatment of endometriosis even after multiple IVF failures.

-----

Obstet Gynecol Surv. 2005 Dec;60(12):817-26.
Future perspectives in the medical treatment of endometriosis.
Ferrero S, Abbamonte LH, Anserini P, Remorgida V, Ragni N.
Department of Obstetrics and Gynaecology, San Martino Hospital, University of Genoa, Genoa, Italy. simone.ferrero@fastwebnet.it

In the last few years, our understanding of the pathogenesis of endometriosis at the cellular and molecular levels has improved significantly. This may give us the opportunity to use new, specific agents for the treatment of this disorder. Despite the effectiveness of the available treatments, novel therapeutic strategies may improve our ability to eliminate endometriotic lesions when present and to prevent the recurrence of endometriosis after surgical treatment. This review focuses on the new, experimental approaches to the medical treatment of endometriosis and its symptoms. The blockage of aromatase activity in endometriotic lesions with an aromatase inhibitor may represent a new step in the medical treatment of endometriosis. Preliminary clinical studies have demonstrated the efficacy of third-generation nonsteroidal aromatase inhibitors (ie, anastrozole and letrozole) in reducing the intensity of pain symptoms associated with the presence of endometriosis. The new selective progesterone receptor modulators may represent a valid hormonal treatment option. Therapeutic manipulation of the immune system through TNFalpha inhibitors may be beneficial in women with endometriosis. New pharmaceutical agents affecting inflammation, angiogenesis, and matrix metalloproteinase activity may prevent or inhibit the development of endometriosis. Further clinical trials may determine if these new therapies are superior to current medical treatment strategies for endometriosis. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians Learning. OBJECTIVES: After completion of this article, the reader should be able to describe the new experimental medical treatments of endometriosis, state that the clinical use of nonsteroidal aromatase inhibitors for endometriosis appears to be efficacious but is based on preliminary clinical data, and recall that the drugs used for endometriosis in the future may include manipulation of the immune system.

-----

Hum Reprod Update. 2005 Nov-Dec;11(6):595-606. Epub 2005 Sep 19.
Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications.
Fauconnier A, Chapron C.
Unite Inserm 149, Recherches Epidemiologiques en Sante Perinatale et Sante des Femmes, Port-Royal.

The relationship between chronic pelvic pain symptoms and endometriosis is unclear because painful symptoms are frequent in women without this pathology, and because asymptomatic forms of endometriosis exist. Our comprehensive review attempts to clarify the links between the characteristics of lesions and the semiology of chronic pelvic pain symptoms. Based on randomized trials against placebo, endometriosis appears to be responsible for chronic pelvic pain symptoms in more than half of confirmed cases. A causal association between severe dysmenorrhoea and endometriosis is very probable. This association is independent of the macroscopic type of the lesions or their anatomical locations and may be related to recurrent cyclic micro-bleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhoea. There are histological and physiopathological arguments for the responsibility of deeply infiltrating endometriosis (DIE) in severe chronic pelvic pain symptoms. DIE-related pain may be in relation with compression or infiltration of nerves in the sub-peritoneal pelvic space by the implants. The painful symptoms caused by DIE present particular characteristics, being specific to involvement of precise anatomical locations (severe deep dyspareunia, painful defecation) or organs (functional urinary tract signs, bowel signs). They can thus be described as location indicating pain. A precise semiological analysis of the chronic pelvic pain symptoms characteristics is useful for the diagnosis and therapeutic management of endometriosis in a context of pain.

-----

Fertil Steril. 2005 Nov;84(5):1375-87.
Treatment of symptomatic rectovaginal endometriosis with an estrogen-progestogen combination versus low-dose norethindrone acetate.
Vercellini P, Pietropaolo G, De Giorgi O, Pasin R, Chiodini A, Crosignani PG.
Clinica Ostetrica e Ginecologica I, University of Milan, Istituto Luigi Mangiagalli, Milan, Italy. paolo.vercellini@unimi.it

OBJECTIVE: To evaluate the efficacy, safety, and tolerability of an estrogen-progestogen combination versus low-dose norethindrone acetate in the treatment of persistent pain after surgery for symptomatic rectovaginal endometriosis. DESIGN: Randomized controlled trial. SETTING: Academic center. PATIENT(S): Ninety women with recurrent moderate or severe pelvic pain after unsuccessful conservative surgery for symptomatic rectovaginal endometriosis. INTERVENTION(S): Twelve-month, continuous treatment with oral ethinyl E2, 0.01 mg, plus cyproterone acetate, 3 mg/day, or norethindrone acetate, 2.5 mg/day. MAIN OUTCOME MEASURE(S): Degree of satisfaction with therapy. RESULT(S): Seven women in the ethinyl E2 plus cyproterone acetate arm and five in the norethindrone acetate arm withdrew because of side effects (n=5), treatment inefficacy (n=6), or loss to follow-up (n=1). At 12 months, dysmenorrhea, deep dyspareunia, nonmenstrual pelvic pain, and dyschezia scores were substantially reduced without major between-group differences. Both regimens induced minor unfavorable variations in the serum lipid profile. According to an intention-to-treat analysis, 28 (62%) out of 45 patients in the ethinyl E2 plus cyproterone acetate group and 33 (73%) out of 45 in the norethindrone acetate group were satisfied with the treatment received. CONCLUSION(S): Low-dose norethindrone acetate could be considered an effective, tolerable, and inexpensive first-choice medical alternative to repeat surgery for treating symptomatic rectovaginal endometriotic lesions in patients who do not seek conception.

-----

Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004753.
Non-steroidal anti-inflammatory drugs for pain in women with endometriosis.
Allen C, Hopewell S, Prentice A, Allen C.

BACKGROUND: Endometriosis is a common gynaecological condition that affects women and can lead to painful symptoms and infertility. It affects women's quality of life greatly, impacting on their careers, everyday activities, sexual and non-sexual relationships, and fertility. Non-steroidal anti-inflammatory drugs (NSAIDs) are the most commonly used first-line treatment for endometriosis. OBJECTIVES: To assess the effects of NSAIDs for the management of pain in women with endometriosis compared to placebo, other NSAIDs, other pain management drugs, or no treatment. SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Trials Register (May 2005) published in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to May 2005), EMBASE (1980 to May 2005) and the reference lists from relevant publications. Experts in the field were also contacted for information about possible studies. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) describing the use of NSAIDs in the treatment of endometriosis in women of all ages. DATA COLLECTION AND ANALYSIS: Two review authors (CA and SH) independently read and extracted data from each of the included studies. Crossover trials were analysed using the inverse variance method in RevMan to calculate the odds ratio for binary outcomes. MAIN RESULTS: Two trials were identified but only one trial, with 24 women, was included in the analysis. Comparing NSAIDs (naproxen) to placebo, there was no evidence of a positive effect on pain relief (odds ratio (OR) 3.27, 95% CI 0.61 to 17.69) in women with endometriosis. There was also inconclusive evidence to indicate whether women taking NSAIDs (naproxen) were less likely to require additional analgesia (OR 0.12, 95% CI 0.01 to 1.29) or experience side effects (OR 0.46, 95% CI 0.09 to 2.47) when compared to placebo. AUTHORS' CONCLUSIONS: There is inconclusive evidence to show whether NSAIDs (naproxen) are effective in managing pain caused by endometriosis. There is no evidence to show whether any individual NSAID is more effective than another. As shown in other Cochrane reviews, women using NSAIDs need to be aware of the possibility that these drugs may cause unintended effects.

-----

Fertil Steril. 2005 Oct;84(4):1033-6.
Role of the vaginally administered aromatase inhibitor anastrozole in women with rectovaginal endometriosis: a pilot study.
Hefler LA, Grimm C, van Trotsenburg M, Nagele F.
Division of Gynecologic Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria.

In the present nonrandomized pilot study we determined the role of the vaginally administered aromatase inhibitor anastrozole (0.25 mg anastrozole/d for 6 months) in the treatment of women with histologically proven rectovaginal endometriosis. In a series of 10 patients, dysmenorrhea, physical and social functioning, but not chronic pelvic pain and dyspareunia, improved during therapy.

-----

Zentralbl Gynakol. 2005 Oct;127(5):308-13.
[Guidelines for the use of GnRH-analogues in the treatment of endometriosis]
[Article in German]
Schweppe KW.
Frauenklinik der Ammerland Klinik GmbH, Akademisches Lehrkrankenhaus der Universitat Gottingen. schweppe@ammerland-klinik.de

Today GnRH-Analogues are the most effective substances for the regression of endometriosis and endometriosis related complaints. In combination with add-back medication the treatment is effective with only few tolerable side effects. The different types of GnRH-Analogues are equally effective, but depot preparation have the best compliance. The tailored application of GnRH-Analogues preoperatively, postoperatively or instead of surgery is dependent on the individual situation of the patient and dependent on the proliferative activity, localisation, type and stage of the disease.

-----

Eur J Obstet Gynecol Reprod Biol. 2005 Sep 23; [Epub ahead of print]
Laparoscopic treatment of endometriosis in teenagers.
Stavroulis AI, Saridogan E, Creighton SM, Cutner AS.
Elizabeth Garrett Anderson and Obstetric Hospital, University College London Hospitals NHS Foundation Trust, Huntley Street, London WC1E 6DH, UK.

OBJECTIVES:: To determine the frequency and severity of endometriosis in adolescent and teenager girls with chronic pelvic pain (CPP) who fail to respond to medical treatment and to evaluate the outcome of radical laparoscopic surgery for severe endometriosis. DESIGN:: Retrospective review of case records of all girls under the age of 21 years who underwent diagnostic and/or operative laparoscopy for CPP unresponsive to medical treatment between January 2001 and December 2003. The operative findings and the response to surgery were retrospectively reviewed. RESULTS:: Thirty-one girls were referred. No pelvic abnormalities were detected in 11 patients (35.5%). Endometriosis was detected in 11 (35.5%). Six had severe endometriosis. Other diagnoses included: non-functional non-endometriotic ovarian cyst (4 patients), functional ovarian cyst (1 patient), hydrosalpinx (bilateral, 1 patient; unilateral, 1 patient) and obstructed uterine horn (2 patients). Of those with severe disease all six were treated laparoscopically without complications. Five were rendered pain free and one had an improvement in symptoms. CONCLUSIONS:: Endometriosis can occur in adolescent and teenager girls. Laparoscopy should be carried out in all adolescents and teenagers with CPP unresponsive to medical treatment. This the first study reporting the outcome of radical excision treatment for severe endometriosis in this age group and early results are encouraging.

-----

Hum Reprod. 2005 Sep 21; [Epub ahead of print]
Subcutaneous depot medroxyprogesterone acetate versus leuprolide acetate in the treatment of endometriosis-associated pain.
Crosignani PG, Luciano A, Ray A, Bergqvist A.
Director, I Clinica Ostetrica e Ginecologica - Universita di Milano, Via Commenda 12 20122 Milano, Italy.

BACKGROUND: A clinical study compared efficacy and safety of depot medroxyprogesterone acetate (DMPA) with leuprolide for endometriosis-associated pain. METHODS: This multicentre, 18 month, evaluator-blinded, comparator-controlled trial randomized 300 women with laparoscopically diagnosed endometriosis to 6 month treatment with subcutaneous injection of 104 mg/0.65 ml DMPA (DMPA-SC 104) every 3 months or leuprolide (3.75 mg monthly or 11.25 mg every 3 months), with 12 months post-treatment follow-up. Endpoints included patient response to treatment in five signs/symptoms (dysmenorrhoea, dyspareunia, pelvic pain, pelvic tenderness, induration) and changes in bone mineral density (BMD) and productivity at 6 and 18 months. RESULTS: DMPA-SC 104 and leuprolide produced equivalent (P < 0.02) reductions in at least four pain categories and significant (P < 0.001) improvements in composite score at months 6 and 18. At month 6, reductions in total hip and lumbar spine BMD were significantly less (P < 0.001) with DMPA-SC 104 versus leuprolide. BMD returned to pre-treatment levels 12 months post-treatment in the DMPA-SC 104 but not the leuprolide group. Total productivity also significantly (P </= 0.05) improved in both groups at 6 and 18 months. CONCLUSIONS: DMPA-SC 104 reduces endometriosis-associated pain as effectively as leuprolide and improves productivity with significantly less BMD decline.

-----

Eur J Obstet Gynecol Reprod Biol. 2005 Sep 14; [Epub ahead of print]
Efficacy of laparoscopic excision of visually diagnosed peritoneal endometriosis in the treatment of chronic pelvic pain.
Wykes CB, Clark TJ, Chakravati S, Mann CH, Gupta JK.
Academic Department of Obstetrics & Gynaecology, Birmingham Women's Hospital, Birmingham B15 2TG, UK.

OBJECTIVE:: To determine the efficacy of laparoscopic excision of visually diagnosed endometriosis in the treatment of chronic pelvic pain. STUDY DESIGN:: Sixty-two women with chronic pelvic pain and who underwent laparoscopic excision of visually diagnosed peritoneal lesions suggestive of endometriosis returned postal questionnaires. The main outcomes measures were change in pelvic pain symptoms measured on a continuous and ordinal scale and patient satisfaction following treatment. Secondary outcomes were quality of life, time off work and use of health service resources. RESULTS:: 42/62 (68%) women with an average follow up time of 13 months (range 6-38 months) returned completed outcome questionnaires. The mean amount of pelvic pain was reduced following surgery compared to immediately prior to treatment, regardless of the nature of the pain (P<0.05). Overall, 67% (95% CI 50-80%) of women reported improvement in pain symptoms and 71% (95% CI 55-84%) were satisfied with the results of treatment. Satisfaction with treatment was comparable whether the visual diagnosis of peritoneal endometriosis was confirmed histologically or not (62% versus 64%, P=1.0). CONCLUSION:: Laparoscopic excision of visually diagnosed endometriosis appears to be efficacious in the treatment of women with chronic pelvic pain. The launch of a long-term randomised controlled trial to confirm these provisional results is now required.

-----

Gynecol Endocrinol. 2005 Aug;21(2):93-100.
Is there any correlation between stages of endometriosis and severity of chronic pelvic pain? Possibilities of treatment.
Szendei G, Hernadi Z, Devenyi N, Csapo Z.

We report herein findings on 181 patients, suffering from pelvic endometriosis confirmed by histology, whose main symptom was chronic pelvic pain (CPP). They attended the outpatient clinic at the 1st Department of Obstetrics and Gynaecology, Semmelweis University in Budapest, between 1 January 1995 and 1 January 2000. The extent of pelvic endometriosis was determined on the basis of the 1985 revised scoring system of the American Fertility Society (R-AFS). The short form of the McGill pain questionnaire was used for the evaluation of CPP. After the first operative intervention, therapy with a gonadotropin-releasing hormone (GnRH) analog was given for 6 months. Second-look laparoscopy was performed 8-10 weeks after the end of GnRH-analog treatment, which was followed by a non-conventionally administered, monophasic oral contraceptive (OC) treatment. In the long term, 118 patients received the non-conventionally administered, monophasic OC treatment, which contained a third-generation progestogen, to be taken continuously for at least 6 months. The other 63 patients who did not receive OC treatment for one reason or another were evaluated as a control group. We analyzed data on CPP before the first surgical intervention, then following therapy with the GnRH analog at the second-look operation, and then after 6, 12, 18 and 24 months. We also reviewed potential causes of CPP, especially focused on endometriosis. No correlation was found between the stage of endometriosis according to R-AFS score and the severity of CPP. At the 24-month follow-up after second-look laparoscopy, the non-conventionally administered monophasic OC treatment was found not only to significantly reduce pain scores, but also the required radical operative solution (hysterectomy plus bilateral adnexectomy) for CPP by OC users.

-----

Curr Opin Obstet Gynecol. 2005 Aug;17(4):399-402.
Outcomes and treatment options in rectovaginal endometriosis.
Emmanuel KR, Davis C.
The Centre for Reproductive Medicine, St Bartholomew's Hospital, London, UK.

PURPOSE OF REVIEW: This review aims to explore the recent literature surrounding the role of colorectal surgery in rectovaginal endometriosis. RECENT FINDINGS: Recent findings would suggest that excision of a portion of the rectum along with complete excision of surrounding endometriosis is beneficial in terms of improvement in quality of life and recurrence of disease. However, further randomized controlled trials are needed to clarify this finding. SUMMARY: The optimal management of women with deeply infiltrating rectovaginal endometriosis remains a challenge to physicians involved in this disease process. The choice between medical and surgical treatments is not clearly defined, and neither is the role of adjunctive medical therapy prior to or following surgery. It is only when these questions have been asked in the context of well conducted clinical trials, with good outcome data, can the answers be given.

-----

Curr Opin Obstet Gynecol. 2005 Aug;17(4):359-65.
The role of the levonorgestrel-releasing intrauterine device in the management of symptomatic endometriosis.
Vercellini P, Vigano P, Somigliana E.
Obstetrics and Gynecology Clinic, Luigi Mangiagalli Institute, University of Milan, Milan, Italy.

PURPOSE OF REVIEW: The aim of this article is to evaluate the biological rationale for the use of an intrauterine device releasing 20 mug/day of levonorgestrel in women with endometriosis, and to assess its efficacy in relieving pelvic pain symptoms. RECENT FINDINGS: Levonorgestrel induces endometrial glandular atrophy and extensive decidual transformation of the stroma, downregulates endometrial cell proliferation, increases apoptotic activity, and has antiinflammatory and immunomodulatory effects. Up to 85% of patients wearing the device have anovulatory cycles during the first 3 months of use, but the proportion falls to below 35% by 12 months. After the first year of use, a 70-90% reduction in monthly blood loss is observed; few women report intermenstrual bleeding and about 20-30% amenorrhea. This is advantageous in patients experiencing dysmenorrhea. Although it is maintained that the hormonal activity of the levonorgestrel intrauterine device is local, a systemic effect secondary to uterine absorption of levonorgestrel is probable. The levonorgestrel intrauterine device has proven effective in relieving pelvic pain symptoms caused by peritoneal and rectovaginal endometriosis and in reducing the risk of recurrence of dysmenorrhea after conservative surgery. SUMMARY: Intrauterine administration of levonorgestrel with direct distribution to pelvic tissues would imply a local concentration greater than plasma levels. This could result in a superior effectiveness with limited adverse effects and increased patient compliance during long-term treatment. Further trials are needed, however, to verify whether the good results observed are maintained during an entire 5-year period, to confirm the efficacy on dyspareunia and dyschezia, and to compare the effects of the levonorgestrel intrauterine device with those of other treatment options.

-----

Fertil Steril. 2005 Aug;84(2):300-4.
Anastrazole and oral contraceptives: a novel treatment for endometriosis.
Amsterdam LL, Gentry W, Jobanputra S, Wolf M, Rubin SD, Bulun SE.
Indiana University School of Medicine, Indianapolis, Indiana, USA.

OBJECTIVE: To establish the use of aromatase inhibitors as a therapeutic option for endometriosis. DESIGN: Prospective open-label Food and Drug Administration phase 2 trial with Institutional Review Board approval. SETTING: Outpatient tertiary care centers. PATIENT(S): Fifteen premenopausal patients with documented refractory endometriosis and chronic pelvic pain. INTERVENTION(S): After a 1-month washout of endometriosis hormone therapies, women took 1 mg anastrazole (Arimidex; AstraZeneca, Wilmington, DE) and one tablet of 20 microg ethinyl estradiol/0.1 mg levonorgestrel (Alesse; Wyeth, Madison, NJ) daily for 6 months. MAIN OUTCOME MEASURE(S): An analog pain scale recorded pelvic pain in daily diaries and surveys at baseline and after each treatment month. Side effects, blood counts, liver and renal function tests, cholesterol levels, and bone density were monitored. RESULT(S): Fourteen of 15 patients achieved significant pain reduction. Median pain scores decreased 55% after 6 months, while mean pain scores decreased 40%. Pain reduction comparing each treatment month to baseline achieved statistical significance. Average pain scores began dropping after only 1 treatment month and continued decreasing each additional month. No organ system experienced adverse effects. Estradiol levels were suppressed during treatment. Side effects were mild and improved over time. CONCLUSION(S): Fourteen of 15 patients with refractory endometriosis achieved significant pain relief using anastrazole and 20 microg ethinyl estradiol/0.1 mg levonorgestrel with minimal side effects. This treatment for endometriosis is a promising new modality that warrants further investigation.

-----

Hum Reprod Update. 2005 Jul 8; [Epub ahead of print]
Noncontraceptive health benefits of combined oral contraception.
[No authors listed]

Contraception is one of the keystones of reproductive health. The availability of effective contraception has helped to change dramatically the structure of the world's population during the last 50 years, through a demographic transition involving lower fertility rates and longer survival. As the transition evolves more slowly in developing countries, different effects on population structures contribute to civil strains. Oral contraception (OC) is an extremely effective method of contraception that also confers health benefits beyond pregnancy prevention. Notable effects on the reproductive system include relief from troublesome symptoms associated with menstruation such as heavy periods, painful periods and irregular bleeding. Many women also have improvement in acne and hirsutism. Moreover, OCs may be used to treat menorrhagia or symptomatic endometriosis. Use of OCs is associated with a long lasting reduction in the risk of developing cancer of the ovary and the endometrium. The effects on benign breast disease (BBD), bone health and colon cancer are less clear and merit further investigation.

-----

Obstet Gynecol Surv. 2005 Jul;60(7):443-5.
The Efficacy, Side-Effects and Continuation Rates in Women With Symptomatic Endometriosis Undergoing Treatment With an Intra-uterine Administered Progestogen (Levonorgestrel): A 3 Year Follow-up.
Lockhat FB, Emembolu JO, Konje JC.
Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, U.K.

Most treatments used to date for endometriosis cause systemic side effects that not only may reduce compliance, but also preclude their long-term use. The levonorgestrel intrauterine system, which delivers the progestogen levonorgestrel directly into the uterine cavity at a rate of 20 mg daily over 5 years, is an alternative approach that avoids the need for repeated or regular treatment. Side effects are fewer than with oral or depot administration. Women treated with levonorgestrel do not require contraception. This study evaluated levonorgestrel in 34 women 18 to 42 years of age who had laparoscopically confirmed minimal or moderate, symptomatic endometriosis. Participants monitored symptoms and side effects using a diary, a visual analog scale, a verbal rating scale, and a pictorial chart of menstrual blood loss and were followed up at 1, 3, and 6 months and then at 6-month intervals for 3 years.Endometriosis was considered to be minimal in 13 women, mild in 15, and moderate in 6. All but 5 women (85%) retained the device during 6 months, 23 (68%) at 12 months, 21 (62%) at 2 years, and 19 (56%) at 3 years. Withdrawals most often were a consequence of irregular bleeding, mostly in the first 6 months. The next most common reasons were pelvic pain and weight gain. There were no expulsions. Symptom scores, assessed by a visual analog scale, showed a continuous decline up to 30 months and then a slight increase. The difference between preinsertion scores and 6-month scores was statistically significant. Ratings of dysmenorrhea decreased throughout follow-up. Responses could not be related to the stage of disease or to symptom scores. Days of pain during a 28-day interval decreased significantly after 12 months and continued to decline, although at a slower rate. Total blood loss was significantly less after 12 months. Side effects included a case of severe depression, 2 instances of uncomfortable intercourse, and 3 women with simple functional ovarian cysts.These findings support the long-term use of intrauterine progestogen in women with symptomatic endometriosis. No medical treatments offer long-term relief of symptoms to the extent apparent in this trial.

-----

Hum Reprod. 2005 Jun 24; [Epub ahead of print]
ESHRE guideline for the diagnosis and treatment of endometriosis.
Kennedy S, Bergqvist A, Chapron C, D'Hooghe T, Dunselman G, Greb R, Hummelshoj L, Prentice A, Saridogan E.
University of Oxford, Oxford, UK.

The objective was to develop recommendations for the diagnosis and treatment of endometriosis and its associated symptoms. A working group was convened comprised of practising gynaecologists and experts in evidence-based medicine from Europe, as well as an endometriosis self-help group representative. After reviewing existing evidence-based guidelines and systematic reviews, the expert panel met on three occasions for a day during which the guideline was developed and refined. Recommendations based solely on the clinical experience of the panel were avoided as much as possible. The entire ESHRE Special Interest Group for Endometriosis and Endometrium was given the opportunity to comment on the draft guideline, after which it was available for comment on the ESHRE website for 3 months. The working group then ratified the guideline by unanimous or near-unanimous voting; finally, it was approved by the ESHRE Executive Committee. The guideline will be updated regularly, and will be made available at http://www.endometriosis.org/guidelines.html with hyperlinks to the supporting evidence, and the relevant references and abstracts. For women presenting with symptoms suggestive of endometriosis, a definitive diagnosis of most forms of endometriosis requires visual inspection of the pelvis at laparoscopy as the 'gold standard' investigation. However, pain symptoms suggestive of the disease can be treated without a definitive diagnosis using a therapeutic trial of a hormonal drug to reduce menstrual flow. In women with laparoscopically confirmed disease, suppression of ovarian function for 6 months reduces endometriosis-associated pain; all hormonal drugs studied are equally effective although their side-effects and cost profiles differ. Ablation of endometriotic lesions reduces endometriosis-associated pain and the smallest effect is seen in patients with minimal disease; there is no evidence that also performing laparoscopic uterine nerve ablation (LUNA) is necessary. In minimal-mild endometriosis, suppression of ovarian function to improve fertility is not effective, but ablation of endometriotic lesions plus adhesiolysis is effective compared to diagnostic laparoscopy alone. There is insufficient evidence available to determine whether surgical excision of moderate-severe endometriosis enhances pregnancy rates. IVF is appropriate treatment especially if there are coexisting causes of infertility and/or other treatments have failed, but IVF pregnancy rates are lower in women with endometriosis than in those with tubal infertility. The management of severe/deeply infiltrating endometriosis is complex and referral to a centre with the necessary expertise is strongly recommended. Patient self-help groups can provide invaluable counselling, support and advice.

-----

Fertil Steril. 2005 Jun;83(6):1729-33.
Long-term follow-up after conservative surgery for bladder endometriosis.
Fedele L, Bianchi S, Zanconato G, Bergamini V, Berlanda N, Carmignani L.
Department of Obstetrics and Gynecology, Ospedale San Paolo, Italy. luigi.fedele@unimi.it

OBJECTIVE: To describe the long-term outcome of surgical conservative treatment of bladder endometriosis. DESIGN: Descriptive study. SETTING: Tertiary referral center for the treatment of endometriosis. PATIENT(S): Forty-seven patients with symptomatic bladder endometriosis. INTERVENTION(S): Partial cystectomy by laparoscopy or laparotomy. MAIN OUTCOME MEASURE(S): Rates of recurrence at a 36-month follow-up. RESULT(S): All 14 patients with isolated bladder dome lesions remained symptom-free. Among the 33 patients with lesions involving the vesical base and vesicouterine septum, cumulative recurrence rates at 36 months were 24.7% and 15.5% for recurrence of symptoms and of clinical-instrumental evidence of lesion, respectively. The only factor influencing rate of recurrence was the extent of surgical excision. When the resection included both the vesical lesion and a 0.5- to 1-cm deep portion of the adjacent myometrium, recurrence was significantly less frequent compared to the removal of the bladder lesion only (7% vs. 37% for symptom recurrence and 0% vs. 26% for clinical-instrumental recurrence, respectively). CONCLUSION(S): Conservative surgical treatment of bladder endometriosis seems effective in ensuring long-term relief in almost all cases of endometriosis affecting the vesical dome, whereas success rates for deeper lesions involving the vesical base and the vesicouterine septum are lower, depending on the degree of surgical radicality.

-----

Treat Endocrinol. 2005;4(3):139-45.
Extended-cycle oral contraception: a new option for routine use.
Nelson AL.
Harbor-UCLA Medical Center, Torrance, California 90209-2910, USA. AnitaNelsonWHC@earthlink.net

Extended use of oral contraceptive (OC) pills can successfully suppress endometrial activity and prevent menstruation for several months. Given that missed menses in women not using hormonal contraception may be of medical concern, understanding how hormonal contraceptives eliminate these concerns is important for both patient and healthcare provider acceptance. OC withdrawal bleeding is an artificial, iatrogenic event, which results from the deliberate, periodic interruption of hormonal support of the endometrium. Historically, it was important to provide periodic bleeding to reassure OC efficacy, but today it is recognized that these bleeding episodes are medically unnecessary and cause patient discomfort and out-of-pocket expenses. Decades of experience with prolonged use of OCs have been accumulated for women with specific menstrual-related problems such as endometriosis, dysmenorrhea, and menstrual migraine headaches. Today there is a US FDA-approved product to routinely reduce the number of withdrawal periods. Clinical trials show that there is an initial increase in unscheduled bleeding and spotting days with extended-cycle OC use, but an absolute decrease in total days of bleeding and spotting from the first cycle of use. Over time, unscheduled bleeding and spotting decreases to rates found with the use of conventional-cycle regimens. Every woman who is interested in using OC pills should be offered the opportunity to choose how to use them, to determine if and when she will have withdrawal bleeding.

-----

Hum Reprod Update. 2005 May-Jun;11(3):293-307. Epub 2005 Mar 24.
Selective progesterone receptor modulators and progesterone antagonists: mechanisms of action and clinical applications.
Chabbert-Buffet N, Meduri G, Bouchard P, Spitz IM.
Vascular Medicine Unit, Tenon Hospital APHP, 4 rue de la Chine, F 75020 Paris.

Since the discovery of the antiprogestin mifepristone, hundreds of similar compounds have been synthesized, which can be grouped in a large family of progesterone receptor ligands. This family includes pure agonists such as progesterone itself or progestins and, at the other end of the biological spectrum, pure progesterone receptor antagonists (PA). Selective progesterone receptor modulators (SPRM) have mixed agonist-antagonist properties, and occupy an intermediate position of the spectrum. These compounds have numerous applications in female health care. Mifepristone is used to terminate pregnancy, and as such is commercially available in many countries. The negative abortion-related image of mifepristone has clearly limited the involvement of the major pharmaceutical companies in the development of PA and SPRM. Many PA and SPRM display direct antiproliferative effects in the endometrium, although with variable actions which seem product- and dose-dependent. This property justifies their use in the treatment of myomas and endometriosis. PA also suppress late follicular development, block the LH surge and retard endometrial maturation, which renders them potential estrogen-free contraceptive drugs. SPRM such as asoprisnil are not as effective in blocking the LH surge and appear to target the endometrium directly and produce amenorrhoea. Interestingly, clinical data show that treatment with these compounds is not associated with hypo-estrogenism and bone loss. The potential clinical applications of these compounds cover a broad field and are very promising in major public health areas. These include emergency contraception, long-term estrogen-free contraception (administered alone, or in association with a progestin-only pill to improve bleeding patterns), myomas (where they induce a marked reduction in tumour volume and produce amenorrhoea) and endometriosis. Further developments might also include hormone replacement therapy in post-menopausal women, as well as the treatment of hormone-dependent tumours.

-----

Acta Obstet Gynecol Scand. 2005 Apr;84(4):380-3.
The effect of physical training on bone mineral density in women with endometriosis treated with GnRH analogs: a pilot study.
Bergstrom I, Freyschuss B, Jacobsson H, Landgren BM.
Center for Metabolism and Endocrinology, Karolinska Institutet at Karolinska University Hospital Huddinge, Sweden.

BACKGROUND: The effect of physical training on bone mineral density (BMD) in women with endometriosis treated with gonadotropin-releasing hormone (GnRH) analogs was studied. METHODS: Nineteen Caucasian premenopausal women aged 23-38 years were included in the study. The subjects were all treated with 21.6 mg goserelin during 6 months. The patients were randomized to physical training n=8 or to a control group n=11. The total period of training was 12 months, whereas GnRH treatment was terminated after 6 months. BMD was measured in the femoral neck area and the lumbar spine using dual X-ray absorptiometry (DEXA). This was performed just before treatment, after 6 months and after 12 months. Six women fulfilled the training during 12 months of observation. In the control group 10 women were followed up for 12 months. RESULTS: After 6 months the women in the physical training group were 2.1% below baseline. Six months later these women had gained BMD in the femoral neck and were 0.6% below baseline. Those in the control group lost 2.8% after 6 months and were 3.6% below baseline after 12 months. The difference in loss of BMD after 12 months between the groups was significant 0.029. In the spine there was no significant difference between the two groups. CONCLUSIONS: Physical training in women with endometriosis was found to rebuild bone after treatment with GnRH analogs when compared to a control group. This effect could be demonstrated 6 months after cessation of GnRH treatment.

-----

Hum Reprod. 2005 Mar 24; [Epub ahead of print]
Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis.
Petta CA, Ferriani RA, Abrao MS, Hassan D, Rosa E Silva JC, Pdgaec S, Bahamondes L.
Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medicine, Universidade Estadual de Campinas (UNICAMP), Campinas, Brazil.

BACKGROUND: The objective of this multicentre randomized, controlled clinical trial was to compare the efficacy of a levonorgestrel-releasing intrauterine system (LNG-IUS) and a depot-GnRH-analogue in the control of endometriosis-related pain over a period of six months. METHODS: Eighty-two women, 18 to 40 years of age (mean 30 years), with endometriosis, dysmenorrhoea and/or CPP, were randomized using a computer-generated system of sealed envelopes into either LNG-IUS (n=39) or GnRH analogue (n=43) treatment groups at three university centres. Daily scores of endometriosis-associated CPP were evaluated using the Visual Analogue Scale (VAS), daily bleeding score was calculated from bleeding calendars, and improvement in quality of life was evaluated using the Psychological General Well-Being Index Questionnaire (PGWBI). The pain score diary was based on the VAS in which women recorded the occurrence and intensity of pain on a daily basis. A monthly score was calculated from the result of the sum of the daily scores divided by the number of days in each observation period. RESULTS: CPP decreased significantly from the first month throughout the six months of therapy with both forms of treatment and there was no difference between the groups (P>0.999). In both treatment groups, women with stage III and IV endometriosis showed a more rapid improvement in the VAS pain score than women with stage I and II of the disease (P<0.002). LNG-IUS users had a higher bleeding score than GnRH-analogue users at all time points of observation with 34% and 71% of patients in the LNG-IUS and GnRH-analogue groups, respectively, reporting no bleeding during the first treatment month, and 70% and 98% reporting no bleeding during the sixth month. No difference was observed between groups with reference to improvement in quality of life. CONCLUSIONS: Both, the LNG-IUS and the GnRH-analogue were effective in the treatment of CPP-associated endometriosis, although no differences were observed between the two treatments. Among the additional advantages of the LNG-IUS is the fact that it does not provoke hypoestrogenism and that it requires only one medical intervention for its introduction every 5 years. This device could therefore become the treatment of choice for CPP-associated endometriosis in women who do not wish to conceive.

-----

Fertil Steril. 2005 Mar;83(3):735-8.
Laparoscopic treatment of pelvic pain associated with minimal and mild endometriosis with use of the Helica Thermal Coagulator.
Nardo LG, Moustafa M, Gareth Beynon DW.
Department of Obstetrics and Gynaecology, Frimley Park Hospital, Camberley, Surrey, United Kingdom. luciano.nardo@cmmc.nhs.uk

OBJECTIVE: To investigate the clinical efficacy and safety of Helica Thermal Coagulator (TC) in the treatment of pelvic pain associated with minimal (stage I) and mild (stage II) endometriosis. DESIGN: A clinical observational study. SETTING: A referral center for laparoscopic treatment of endometriosis. PATIENT(S): Eighty-one women with pelvic pain symptoms associated with minimal and mild endometriosis diagnosed at laparoscopy. INTERVENTION(S): Helica TC to treat endometriotic lesions. The revised American Fertility Society (rAFS) classification was used to stage endometriosis. Pain symptoms and patient satisfaction were assessed subjectively at 3 and 6 months follow-up. MAIN OUTCOME MEASURE(S): Improvement or relief of pelvic pain symptoms, and intra- or postoperative complications. RESULT(S): A total of 79 women completed the study to 6 months follow-up. At 3 months, 59 (74.7%) women reported resolution and satisfactory improvement of symptoms, whereas 20 (25.3%) women continued to experience painful symptoms. At 6 months, 69 (87.4%) women reported resolution and satisfactory improvement of symptoms, whereas 9 (11.4%) women reported no changes and 1 (1.2%) woman experienced worsening symptoms. No significant differences were found between minimal and mild disease. No side effects or surgical complications occurred. CONCLUSION(S): Meaningful improvements and relief in clinical symptoms can be obtained with conservative laparoscopic surgery. Helica TC is a simple, effective, and safe device for the treatment of pelvic pain in women with stages I and II endometriosis. This approach requires further evaluation as part of randomized controlled trials.

-----

Minerva Ginecol. 2005 Feb;57(1):55-78
Diagnosis and treatment of endometriosis. A review.
Scarselli G, Rizzello F, Cammilli F, Ginocchini L, Coccia ME.
Department of Gynaecology, Perinatology and Human Reproduction, University of Florence, Florence, Italy.

The correct approach for endometriosis management is still unclear. This review explores recent data concerning diagnosis and treatment of endometriosis, trying to define guidelines for the most appropriate diagnostic approach and therapeutic regimen. At present, laparoscopy is still considered the gold standard in endometriosis diagnosis. The risks and the diagnostic limitations of laparoscopy and the inaccuracy of clinical examination justify the considerable efforts made to improve the diagnosis with imaging techniques. The therapeutic approach is still far from being defined as causal and focuses on management of clinical symptoms of the disease rather than on the disease itself. A first-line medical therapy should be tried in patients with pelvic pain not asking for a pregnancy. Surgical treatment is considered the best treatment for women with pain and or pelvic mass who wish to become pregnant in a short time. For infertile patients, medical therapy has a limited role. The 2 treatment options include surgery or in vitro fertilization (IVF). According to our results, it seems that correct management of infertile women with endometriosis is a combination of surgery and IVF in women who did not obtain post-surgery pregnancy spontaneously.

-----

JSLS. 2005 Jan-Mar;9(1):16-24.
Fertility considerations in laparoscopic treatment of infiltrative bowel endometriosis.
Mohr C, Nezhat FR, Nezhat CH, Seidman DS, Nezhat CR.
Department of Surgery, Stanford University School of Medicine, Stanford, California, USA.

OBJECTIVE: The purpose of this study was to examine our experience with laparoscopic and laparoscopically assisted management of bowel endometriosis and to recommend treatment approaches, considering patient goals for both pain mitigation or fertility, or both. METHODS: The medical records of 187 women treated laparoscopically for intestinal endometriosis were reviewed retrospectively for presenting symptoms, methods of surgical treatment, complications, and efficacy of treating pain and infertility. The extent of resection was determined by the severity of the endometriotic lesion, tempered by the patient's fertility goals. RESULTS: The most common patient complaint preceding surgery was pelvic pain. In addition, 58 (31%) patients experienced impaired fertility. Of the patients available for long-term follow-up, 152 (85%) reported complete or significant long-term pain relief. Complete pain relief in the immediate postoperative period was significantly more likely with partial bowel resection compared with shaving only, 92% vs 80%, respectively, P<0.04. The least invasive procedure, shaving, was associated with a significantly lower complication rate, 6%, compared with 23% for disc excision (P<0.007) and 38% for segmental resection (P<0.001), and higher pregnancy rates. The incidence of pregnancy in patients with a history of infertility was 34% during the follow-up period.

-----

Hum Reprod. 2005 Mar;20(3):789-93. Epub 2004 Dec 17.
The efficacy, side-effects and continuation rates in women with symptomatic endometriosis undergoing treatment with an intra-uterine administered progestogen (levonorgestrel): a 3 year follow-up.
Lockhat FB, Emembolu JO, Konje JC.
Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK.

BACKGROUND: Side-effects and choice of drugs influence compliance during treatment for endometriosis. Progestogen administered by a device with a 5-year lifespan, has been shown to be an effective medical alternative with several advantages. The aims of this study were to investigate its efficacy, continuation rates and side-effects in women with endometriosis over a 3-year period. METHODS: Thirty-four women with laparoscopically confirmed minimal to moderate symptomatic endometriosis offered insertion of an intrauterine device at diagnostic laparoscopy were followed up at 1, 3 and 6 months, and then every 6 months for 3 years. A symptom diary for side-effects, documentation of symptoms on a visual analogue scale (VAS), a verbal rating scale (VRS) and quantified menstrual loss using the pictorial blood loss chart was used to assess response to treatment. RESULTS: The continuation rates were respectively 85%, 68%, 62% and 56% at, 6, 12, 24 and 36 months. Discontinuation rates were highest at <12 months, and most of these were for irregular and intolerable bleeding and persistent pain. An improvement in symptoms was observed throughout the 36 months. The greatest changes in pain assessed by either the VAS or VRS were between the pretreatment scores and those after 12 months (7.7+/-1.3 versus 3.5+/-1.8 for VAS, P<0.001; and 25+/-13.8 versus 14+/-9.4 for VRS, P<0.002). The monthly quantified blood loss fell from 204 (196) pretreatment to 60 (50) at 12 months (P<0.001) and then to 70 (30) after 36 months. The most common side-effects were bleeding irregularities (14.7%), one-sided abdominal pain (11.8%) and weight gain (8.8%). CONCLUSIONS: Intrauterine progestogen is effective in symptom control throughout the 3 years on the device, and discontinuation is greatest between 3 and 6 months. For those patients with improvement in symptoms, it is an acceptable long-term alternative.

-----

Am J Obstet Gynecol. 2005 Feb;192(2):394-400.
Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis.
Darai E, Thomassin I, Barranger E, Detchev R, Cortez A, Houry S, Bazot M.
Service de Gynecologie, Obstetrique et Medecine de la Reproduction,Hopital Tenon, Universite Saint-Antoine Paris VI, Assistance Publique des Hopitaux de Paris, France. emile.darai@tnn.ap-hop-paris.fr

OBJECTIVE: This study was undertaken to evaluate the feasibility and complications of laparoscopic segmental colorectal resection for endometriosis and its efficacy on gynecologic and digestive symptoms. STUDY DESIGN: After magnetic resonance imaging and rectal endoscopic sonographic evaluation of symptomatic colorectal endometriosis, 40 consecutive women requiring colorectal resection were included in this study. Symptom questionnaires were completed before and after the procedure. Perioperative complications and linear intensity scores for several gynecologic and digestive symptoms were recorded. RESULTS: Thirty-six women (90%) underwent laparoscopic segmental colorectal resection and 4 required laparoconversion. Major complications occurred in 4 cases (10%), including 3 rectovaginal fistulae and 1 pelvic abscess. Transient urinary dysfunction occurred in 7 women (17.5%). Median follow-up after colorectal resection was 15 months (3-22 months). Median overall preoperative and postoperative pain scores were 8 +/- 1 (range 4-10) and 2 +/- 2 (0-10), respectively ( P < .0001). Nonmenstrual pelvic pain ( P = .0001), dysmenorrhea ( P < .0001), dyspareunia ( P = .0001), and pain on defecation ( P < .0005) were improved by colorectal resection. Lower back pain and asthenia were not improved. CONCLUSION: Our results suggest that laparoscopic segmental colorectal resection for endometriosis is feasible but carries a risk of major postoperative complications. Colorectal resection improved gynecologic and digestive symptoms, and the overall pain score.

-----

J Fam Plann Reprod Health Care. 2005 Jan;31(1):67-70.
Treatment of pelvic endometriosis with etonogestrel subdermal implant (Implanon).
Yisa SB, Okenwa AA, Husemeyer RP.
University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK.

BACKGROUND: Endometriosis is one of the commonest benign gynaecological disorders and has a peak incidence between 30 and 45 years of age. Treatment options are medical or surgical, depending on the location and extent of the disease and the woman's childbearing aspirations or need for contraception. Over the past five decades several formulations of progestogen have been used to treat endometriosis. METHODS: Our study was not planned research but a series of case studies of women with severe symptoms of endometriosis treated in an innovative way with a new long-acting progestogen contraceptive system (etonogestrel subdermal implant) which could reasonably have been expected to have a favourable effect on their disease and its symptoms. RESULTS: Five women with severe pelvic endometriosis were treated. Two of them were nulliparous and wished to become pregnant in due course; the other three had completed their childbearing and were contemplating hysterectomy. One of the five women had relief of pelvic pain but requested removal of the implant after 3 months because of side effects; the other four remained very satisfied with their treatment for the symptoms of pelvic endometriosis. Two of the four very satisfied women have had their implant replaced and the other two are expected to have their implant replaced when necessary. CONCLUSION: Etonogestrel subdermal implants are an additional treatment option in women with symptoms related to pelvic endometriosis.

-----

Ann N Y Acad Sci. 2004 Dec;1034:326-37.
Surgical management of deeply infiltrating endometriosis: an update.
Chapron C, Chopin N, Borghese B, Malartic C, Decuypere F, Foulot H.
Service de chirurgie gynecologique, Unite de chirurgie, Clinique Universitaire Baudelocque, 123, Boulevard Port-Royal, CHU Cochin-Saint Vincent de Paul, 75014 Paris, France. charles.chapron@cch.ap-hop-paris.fr.

Deeply infiltrating endometriosis (DIE) manifests itself mainly in the form of pain, predominantly deep dyspareunia, and painful functional symptoms that are aggravated monthly during menstruation, with the semiology being directly correlated with the location of the lesions (bladder, rectum). A workup to assess the extent of the disease is necessary to establish an accurate map of the DIE lesions, which is the essential condition to perform complete exeresis. The treatment of first intention is surgical, because medical treatments are only palliative in the majority of cases. Successful treatment depends on achieving radical surgical exeresis. Analysis of the anatomical distribution of the DIE lesions allows a "surgical classification" to be proposed to standardize the modalities of surgical treatment. Further studies are needed to specify the place and modalities of medical treatments preoperatively and postoperatively.

-----

J Reprod Med. 2004 Dec;49(12):955-9.
Short-term postoperative GnRH analogue or danazol treatment after conservative surgery for stage III or IV endometriosis before ovarian stimulation: a prospective, randomized study.
Tsai YL, Hwang JL, Loo TC, Cheng WC, Chuang J, Seow KM.
Departments of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.

OBJECTIVE: To assess the effect of short-term use of a gonadotropin releasing hormone (GnRH) analogue for 3 months before ovarian stimulation in patients with stage III and IV endometriosis after conservative surgery. STUDY DESIGN: Eleven patients were randomly selected to receive intramuscular injections of GnRH analogue, leuprolide acetate (3.75 mg), every 28 days, or 400 mg danazol orally 2 times per day for 3 months before ovarian stimulation after conservative laparoscopic or laparotomy surgeryfor stage III and IV symptomatic endometriosis (group 1), as compared with 30 patients who had received no postoperative treatment with GnRH analogue or danazol but underwent ovarian stimulation immediately after thefirst menses within 3 months postoperatively (group 2). RESULTS: Although the number of oocytes retrieved and number of embryos per cycle were significantly higher in group 1, the pregnancy rate per cycle in group 1 was not significantly different from that in group 2 (18% vs. 20%). The cumulative pregnancy rate at 12 months was 54.5% and 56.7% in group 1 and group 2, respectively. With regard to recurrence of disease after 24 months of follow-up, group 2 had a statistically significantly higher recurrence rate (13.3%) than did group 1 (0%). CONCLUSION: Short-term use of GnRH analogue before ovarian stimulation in women with stage III or IV endometriosis confers no definite benefits on pregnancy rates per cycle when compared with patients who received ovarian stimulation within 3 months after conservative surgery.

-----

J Am Board Fam Pract. 2004 Nov-Dec;17 Suppl 1:S43-7.
Management of pelvic pain from dysmenorrhea or endometriosis.
Nasir L, Bope ET.
Department of Family Medicine, University of Nebraska at Omaha.

Many women suffer from pelvic pain, and a great many visit their family doctor for diagnosis and treatment. Two common causes are primary dysmenorrhea and endometriosis. Primary dysmenorrhea is best treated by prostaglandin inhibition from nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase-2 (COX-2)-specific inhibitors. Oral contraceptives can be added to improve pain control. Endometriosis can be treated with NSAIDs and COX-2-specific inhibitors as well but can also be treated with hormonal manipulation or surgery. Empiric treatment for endometriosis in selected patients is now accepted, making the disorder easier for family physicians to manage.

-----

J Gynecol Obstet Biol Reprod (Paris). 2004 Nov;33(7):600-606.
[Laparoscopic colorectal resection for endometriosis: preliminary results.]
[Article in French]
Marpeau O, Thomassin I, Barranger E, Detchev R, Bazot M, Darai E.
Service de Gynecologie-Obstetrique.

OBJECTIVE: Colorectal endometriosis is source of chronic pelvic pain greatly affecting quality-of-life. Colorectal resection is indicated after failure of medical treatment. Few data are available on complications and functional results after laparoscopic colorectal resection for endometriosis. Therefore, the aims of this prospective study were to evaluate the feasibility, peri-operative complications and functional results of laparoscopic colorectal resection for endometriosis. Materials and Methods. From March 2001 to March 2003, 32 consecutive women with clinically-suspected colorectal endometriosis confirmed by MR imaging and rectal endoscopic sonography were included in this prospective study. RESULTS: Conversion to open surgery was required for four of the 32 women (12.5%). Mean operating time was 6 hours (range 4 to 13). Associated surgical procedures were: adhesiolysis (n=24), ureteral lysis (n=19), ovarian cystectomy (n=11), and hysterectomy (n=4). Mean blood loss was 2.4g/dl (range: 0 to 8.6). Blood transfusion was required in 6 women including two who underwent laparoconversion. Two rectovaginal fistulae (6.3%) occurred requiring a colostomy. Urinary retention was noted in 6 women (15.6%). CONCLUSION: Laparoscopic colorectal resection for endometriosis is feasible and is associated with a significant improvement of symptoms. However, the benefit of this procedure has to be weighed against the high morbidity.

-----

Lancet. 2004 Nov 13;364(9447):1789-99.
Endometriosis.
Giudice LC, Kao LC.
Division of Reproductive Endocrinology and Infertility, Center for Research on Women's Health and Reproduction, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA 94305-5317, USA. giudice@stanford.edu

Endometriosis is an oestrogen-dependent disorder that can result in substantial morbidity, including pelvic pain, multiple operations, and infertility. New findings on the genetics, the possible roles of the environment and the immune system, and intrinsic abnormalities in the endometrium of affected women and secreted products of endometriotic lesions have given insight into the pathogenesis of this disorder and serve as the background for new treatments for disease-associated pain and infertility. Affected women are at higher risk than the general female population of developing ovarian cancer, and they also may be at increased risk of breast and other cancers as well as autoimmune and atopic disorders. Clinicians should assess and follow up affected women for these and other associated disorders. There will probably be a new repertoire of approaches for treatment and perhaps cure of this enigmatic disorder in the near future.

-----

Fertil Steril. 2004 Nov;82(5):1407-11.
Transient abdominal ovariopexy for adhesion prevention in patients who underwent surgery for severe pelvic endometriosis.
Ouahba J, Madelenat P, Poncelet C.
Service de Gynecologie Obstetrique, Hopital Bichat-Claude Bernard, AP-HP, Paris, France.

OBJECTIVE: To assess adhesion reformation and subsequent fertility after a transient ovariopexy performed during severe pelvic endometriosis surgery. DESIGN: Retrospective study. SETTING: University hospital. PATIENT(S): Twenty young women who underwent severe pelvic endometriosis surgery. INTERVENTION(S): Unilateral or bilateral transient ovariopexy to the anterior abdominal wall was performed as the last step in the surgical procedure. Median duration of ovariopexy was 4 days. MAIN OUTCOME MEASURE(S): Adhesion reformation and subsequent fertility. RESULT(S): This well-tolerated procedure induced neither specific complication nor prolonged hospital stay. A second-look laparoscopy, performed in eight patients (40%), has shown a reduction of the occurrence, the extent, and the severity of ovarian adhesions. Two thirds of the suspended ovaries had no or smooth adhesions at second-look laparoscopy, even though all ovaries were initially adherent. Fifteen infertile women without male infertility factors tried actively to conceive after surgery. In this group of patients, four conceived spontaneously, and four conceived after IVF (total pregnancy rate = 53.3%). Seven patients delivered, and one pregnancy is ongoing. Median pregnancy delay was 11.5 months (range, 4-24 months). CONCLUSION(S): Transient ovariopexy appears to be a simple, safe, and effective technique in preventing postoperative adhesion reformation in severe pelvic endometriosis.

-----

Fertil Steril. 2004 Nov;82(5):1303-8.
Add-back therapy in the treatment of endometriosis-associated pain.
Zupi E, Marconi D, Sbracia M, Zullo F, De Vivo B, Exacustos C, Sorrenti G.
Department of Obstetrics and Gynecology, Tor Vergata University, Rome, Italy.

OBJECTIVE: To determine the efficacy of GnRH analogue plus add-back therapy compared with GnRH analogue alone and estroprogestin in patients with relapse of endometriosis-associated pain. DESIGN: Randomized, controlled study. SETTING: University hospital. PATIENT(S): One hundred thirty-three women with relapse of endometriosis-related pain after previous endometriosis surgery. INTERVENTION(S): Forty-six women were treated with GnRH analogue plus add-back therapy, 44 women were given GnRH analogue alone, and 43 women received estroprogestin, for 12 months. MAIN OUTCOME MEASURE(S): Pain evaluation by a visual analogue scale, quality of life in treated patients according to the SF-36 questionnaire, and occurrence of adverse effects, including bone mass density loss, at pretreatment, after 6 months of treatment, at the end of treatment (12 months), and 6 months after discontinuation of treatment. RESULT(S): Patients treated either with GnRH analogue alone or GnRH analogue plus add-back therapy showed a higher reduction of pelvic pain, dysmenorrhea, and dyspareunia than patients treated with oral contraceptive, whereas patients treated with add-back therapy showed a better quality of life, as assessed with the SF-36 questionnaire, and adverse effects rate than the other two groups. CONCLUSION(S): Add-back therapy allows the treatment of women with relapse of endometriosis-associated pain for a longer period, with reduced bone mineral density loss, good control of pain symptoms, and better patient quality of life compared with GnRH analogue alone or oral contraceptive.

-----

Minerva Ginecol. 2004 Oct;56(5):419-35.
Pathophysiology, diagnosis and treatment of endometriosis.
Schindler AE.
Institute for Medical Research and Education, Essen, Germany.

Endometriosis is generally a benign condition. However, there is a tendency towards progression and in part deep infiltrating processes occur, which can lead to obstruction and even silent loss of organ function such as kidney failure. Hereditary, genetic and immunological peculiarities have been found. Important are symptoms such as pain and infertility, which burden the life of the women involved. In spite of extensive research in the past the pathogenesis and epidemiology of the disease are not definitely clarified as yet. The estimated prevalence of endometriosis ranges between 10% and even more than 50% depending on the underlying problems of the women studied. Besides the main location of the disease within the pelvis also extra pelvic locations have been found (lung, lymphnotes, scars). The diagnosis should be established by histological verification. The main therapeutic modalities consist of surgery and medical treatment or combinations, which need to be individually adjusted, because of the high risk of recurrence and progression of the disease. The aim should be early detection and treatment as complete as possible, since symptom relief, resolution or prevention of infertility and decrease of recurrences are at their best under these circumstances.

-----

Fertil Steril. 2004 Oct;82(4):878-84.
Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial.
Abbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R.
University of New South Wales, Sydney, Australia.

OBJECTIVE: To examine the effect on pain and quality of life for women with all stages of endometriosis undergoing laparoscopic surgery compared with placebo surgery. DESIGN: A randomized, blinded, crossover study. SETTING: A tertiary referral unit in a district general hospital. PATIENT(S): Thirty-nine women with histologically proven endometriosis completed the 12-month study. INTERVENTION(S): Women were randomized to receive initially either a diagnostic procedure (the delayed surgical group) or full excisional surgery (the immediate surgery group). After 6 months, repeat laparoscopy was performed, with removal of any pathology present. MAIN OUTCOME MEASURE(S): The end points were changes from baseline values of visual analogue pain scores, validated quality-of-life instruments (EQ-5D and SF-12), and sexual activity questionnaire scores. Patients and assessors of outcomes were blinded to the treatment-group assignment. RESULT(S): Significantly more of the 39 women operated on according to protocol reported symptomatic improvement after excisional surgery than after placebo: 16 of 20 (80%) vs. 6 of 19 (32%); chi(2)(1) = 9.3.Other aspects of quality of life were also significantly improved 6 months after excisional surgery but not after placebo. Progression of disease at second surgery was demonstrated for women having only an initial diagnostic procedure in 45% of cases, with disease remaining static in 33% and improving in 22% of cases. Nonresponsiveness to surgery was reported in 20% of cases. CONCLUSION(S): Laparoscopic excision of endometriosis is more effective than placebo at reducing pain and improving quality of life. Surgery is associated with a 30% placebo response rate that is not dependent on severity of disease. Approximately 20% of women do not report an improvement after surgery for endometriosis.

-----

BJOG. 2004 Sep;111(9):950-9.
A double-blind randomised controlled trial of laparoscopic uterine nerve ablation for women with chronic pelvic pain.
Johnson NP, Farquhar CM, Crossley S, Yu Y, Peperstraten AM, Sprecher M, Suckling J.
Department of Obstetrics and Gynaecology, National Women's Hospital, University of Auckland, Auckland, New Zealand.

Objective To determine the effectiveness of laparoscopic uterine nerve ablation (LUNA) for chronic pelvic pain in women with endometriosis and women with no laparoscopic evidence of endometriosis. Design A prospective double-blind randomised controlled trial (RCT). Setting Single-centre, secondary-level gynaecology outpatient service and tertiary-level pelvic pain and endometriosis outpatient service in Auckland, New Zealand. Population One hundred and twenty-three women undergoing laparoscopy for investigation and management of chronic pelvic pain, 56 with no laparoscopic evidence of endometriosis and 67 with endometriosis. Methods Women were randomised from the two populations, firstly those with no evidence of endometriosis and secondly those undergoing laparoscopic surgical treatment for endometriosis, to receive LUNA or no LUNA. Participant and assessor blinding was employed. Follow up for pain outcomes was undertaken at 24 hours, 3 months and 12 months. Main outcome measures Changes in non-menstrual pelvic pain, dysmenorrhoea, deep dyspareunia and dyschezia were assessed primarily by whether there was a decrease in visual analogue score for these types of pain of 50% or more from baseline and additionally whether there was a significantly different change in median visual analogue score. The numbers requiring further surgery or starting a new medical treatment for pelvic pain and complications were also measured. Results There was a significant reduction in dysmenorrhoea at 12 month follow up in women with chronic pelvic pain in the absence of endometriosis who underwent LUNA (median change in visual analogue scale (VAS) from baseline -4.8 versus-0.8 (P= 0.039), 42.1%versus 14.3% experiencing a successful treatment defined as a 50% or greater reduction in visual analogue pain scale for dysmenorrhoea (P= 0.045). There was no significant difference in non-menstrual pelvic pain, deep dyspareunia or dyschezia in women with no endometriosis undergoing LUNA versus no LUNA. The addition of LUNA to laparoscopic surgical treatment of endometriosis was not associated with a significant difference in any pain outcomes. Conclusions LUNA is effective for dysmenorrhoea in the absence of endometriosis, although there is no evidence of effectiveness of LUNA for non-dysmenorrhoeic chronic pelvic pain or for any type of chronic pelvic pain related to endometriosis.

-----

Fertil Steril. 2004 Aug;82(2):437-41.
Sclerotherapy with 5% tetracycline is a simple alternative to potentially complex surgical treatment of ovarian endometriomas before in vitro fertilization.
Fisch JD, Sher G.
Sher Institute for Reproductive Medicine, 3121 S. Maryland Parkway, Las Vegas, Nevada 89109, USA. jfisch@sherinstitute.com

OBJECTIVE: Conventional treatment of endometriosis involves drainage and removal of the cyst wall, which often results in inadvertent resection of normal ovarian tissue. We previously reported that 12 patients were successfully treated with sclerotherapy using 5% tetracycline. We now report our experience with sclerotherapy before in vitro fertilization (IVF) in an additional 20 patients with ovarian endometriomas. DESIGN: Prospective, cohort. SETTING: Private practice. PATIENT(S): Women (n = 32) with sonographic evidence of an ovarian endometrioma were offered sclerotherapy in lieu of laparoscopy. INTERVENTION(S): Sclerotherapy was performed under conscious sedation and transvaginal ultrasound guidance. An 18-gauge, single-lumen needle was inserted into the endometrioma, and the cyst contents were sequentially aspirated and flushed with sterile saline until the aspirated fluid was clear. Tetracycline (5%) (5-10 mL) was then instilled into the cyst. Saline was injected into the cul-de-sac to dilute any tetracycline that may have leaked. The fluid was then removed. Ultrasound was performed 6 weeks later to assess the efficacy of treatment. MAIN OUTCOME MEASURE(S): Resolution of endometrioma and subsequent IVF pregnancy rate. RESULT(S): Complete resolution was observed in 24 (75%) of 32 patients, at follow-up exam. Repeat aspiration of watery fluid was required in eight patients before resolution. Repeat treatment with tetracycline was needed in two patients. Only one patient did not ultimately respond. In vitro fertilization was performed in 28 patients; an ongoing gestation resulted in 16 (57%) from the next cycle. CONCLUSION(S): Sclerotherapy with 5% tetracycline is a simple, effective (and, in our limited series, safe) alternative to surgical intervention for treatment of endometriomas before IVF.

-----

Cochrane Database Syst Rev. 2004;(3):CD003678.
Pre and post operative medical therapy for endometriosis surgery.
Yap C, Furness S, Farquhar C.
Department of Obstetrics & Gynaecology, Singapore General Hospital, Outram Road, Singapore, SINGAPORE, 169608.

BACKGROUND: Endometriosis is a common gynaecological condition which affects approximately 10% of women of reproductive age (Askenazi 1997). There is a range of symptoms and most commonly women present with dysmenorrhoea, pelvic pain, infertility or a pelvic mass. Direct visualisation and biopsy during laparoscopy or laparotomy is the gold standard diagnostic test for this condition and enables the gynaecologist to identify the location, extent and severity of the disease. Surgical therapy can be performed concurrently with diagnostic surgery and may include removal (excision) or destruction (ablation) of endometriotic tissue, division of adhesions and removal of endometriotic cysts. Laparoscopic excision or ablation of endometriosis has been shown to be effective in the management of pain in mild-moderate endometriosis. Adjunctive medical treatment pre or post-operatively may prolong the symptom-free interval. OBJECTIVES: To determine the effectiveness of systemic medical therapies used for hormonal suppression before or after surgery for endometriosis, or before and after surgery for endometriosis in the eradication of endometriosis, improvement of symptoms, pregnancy rates and overall tolerability by comparing them with no treatment or placebo. SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility group trials register (searched 10 September 2003), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3 2003), MEDLINE (January 1966 to September 2003), EMBASE (January 1985 to September 2003) and reference lists of articles. We also contacted researchers in the field. SELECTION CRITERIA: Trials were included if they were randomised controlled trials of the use of systemic medical therapies for hormonal suppression before or after, or before and after surgery for endometriosis. DATA COLLECTION AND ANALYSIS: Data extraction and quality assessment was performed independently by using relative risk or weighted mean difference and 95% confidence intervals. MAIN RESULTS: Eleven trials were included in the review. One study comparing pre-surgical medical therapy with surgery alone showed a significant improvement in AFS scores in the medical therapy group (WMD -9.60, 95% CI -11.42 to -7.78) but this may or may not be associated with better outcomes for the patients. Post surgical hormonal suppression of endometriosis compared to surgery alone (either no medical therapy or placebo) showed no benefit for the outcomes of pain or pregnancy rates but a significant improvement in disease recurrence (AFS scores (WMD -2.30, 95% CI -4.02 to -0.58)). There were no trials identified in the search that compared hormonal suppression of endometriosis before and after surgery with surgery alone. There is no significant difference between pre surgery hormonal suppression and post surgery hormonal suppression for the outcome of pain in the one trial identified (RR 1.01, 95% CI 0.49 to 2.07). Information concerning AFS scores and ease of surgery was reported only as a descriptive summary so any difference between the groups can not be quantified from the information in the report of this trial. REVIEWERS' CONCLUSIONS: There is insufficient evidence from the studies identified to conclude that hormonal suppression in association with surgery for endometriosis is associated with a significant benefit with regard to any of the outcomes identified. There may be a benefit of improvement in AFS scores with the pre-surgical use of medical therapy. The possible benefit should be weighed in the context of the adverse effects and costs of these therapies.

-----

Curr Opin Obstet Gynecol. 2004 Aug;16(4):299-303.
The effectiveness of laparoscopic excision of endometriosis.
Garry R.
University of Western Australia, School of Women's and Infants' Health, King Edward Memorial Hospital, Subiaco, Western Australia. rgarry@obsgyn.uwa.edu.au

PURPOSE OF REVIEW: The optimum method for the treatment of endometriosis remains unclear. This review explores recent data concerning the effectiveness of laparoscopic excision and associated therapies, to guide clinicians in their selection of the most appropriate therapeutic regimen. RECENT FINDINGS: Large, long-term, prospective studies and a placebo-controlled, randomized, controlled trial suggest that laparoscopic excision is an effective treatment approach for patients with all stages of endometriosis. The result of such laparoscopic excision may be improved if affected bowel, bladder and other involved structures are also excised. Adjuvant therapies such as the levonorgestrel intrauterine system and pre-sacral neurectomy may further improve outcomes. Ovarian endometrioma are invaginations of the uterine cortex, and surgical stripping of this cortex removes many primordial follicles. Despite this apparent disadvantage, stripping of the capsule is associated with better subsequent pregnancy rates and lower recurrence rates than the more conservative approach of thermal ablation to the superficial cortex. SUMMARY: Laparoscopic excision is currently the 'gold standard' approach for the management of endometriosis, and results may be improved with careful use of appropriate techniques and suitable adjuvant therapies. Copyright 2004 Lippincott Williams and Wilkins

-----

Fertil Steril. 2004 Jul;82(1):239-40.
A danazol-loaded intrauterine device decreases dysmenorrhea, pelvic pain, and dyspareunia associated with endometriosis.
Cobellis L, Razzi S, Fava A, Severi FM, Igarashi M, Petraglia F.

A danazol-loaded intrauterine device (IUD) containing 300-400 mg of danazol was inserted for 6 months in a group of women (n = 18) (median age 36.6 years; age range: 30 to 46 years) with a histologic diagnosis of endometriosis, referred for recurrent pelvic pain. Dysmenorrhea, dyspareunia, and pelvic pain significantly decreased after the first month, with a persistent effect during the 6 months of IUD insertion. These results show that a danazol-loaded IUD is an effective conservative therapy for patients with endometriosis-related pelvic pain.

-----

Fertil Steril. 2004 Jun;81(6):1522-7.
An open and randomized study comparing the efficacy of standard danazol and modified triptorelin regimens for postoperative disease management of moderate to severe endometriosis.
Wong AY, Tang L.
Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Hong Kong SAR, People's Republic of China. alicewyk@netvigator.com

OBJECTIVE: To compare the efficacy of danazol and triptorelin (Decapeptyl CR, Ferring, Kiel, Germany) in the management of moderate and severe endometriosis in terms of symptom control and revised American Fertility Society (AFS) score reduction, and to evaluate the hormonal profile of patients treated with triptorelin every 6 weeks. DESIGN: Open and randomized trial. SETTING: Kwong Wah Hospital, a large public hospital in an urban location (Hong Kong). PATIENT(S): Forty patients after their first conservative operation for endometriosis, with surgical confirmation of revised AFS stage III or IV endometriosis. INTERVENTION(S): Postoperative 6 months' therapy of danazol or triptorelin every 6 weeks, postmedical therapy second-look laparoscopy. MAIN OUTCOME MEASURE(S): Symptom control and patients' tolerance during medical therapy, posttherapy revised AFS score, hormonal profile during triptorelin therapy. RESULT(S): Pain control was similar between danazol and triptorelin therapy. There was less breakthrough bleeding with triptorelin. More patients failed to complete the whole course of danazol because of its side effects. The revised AFS score at second-look laparoscopy did not show a significant difference between the two medications. Adequate pituitary suppression was observed with injection of triptorelin every 6 weeks. CONCLUSION(S): Lengthening of triptorelin administration intervals from 4 weeks to 6 weeks is effective in maintaining a hypoestrogenic state. Patients were more compliant with triptorelin than danazol. Thus, triptorelin injection every 6 weeks is more cost-effective than conventional regimens.

-----

Expert Opin Emerg Drugs. 2004 May;9(1):167-177.
Emerging drugs for endometriosis.
Fedele L, Berlanda N.
San Paolo Hospital.

Medical treatment of endometriosis relies on drugs that suppress ovarian steroids and induce an hypoestrogenic state that causes atrophy of ectopic endometrium. Gonadotrophin-releasing hormone (GnRH) analogues, danazol, progestogens and oestrogen-progestin combinations have all proven effective in relieving pain and reducing the extent of endometriotic implants. However, symptoms often recur after discontinuation of therapy and hypoestrogenism-related side effects limit the long-term use of most medications. Furthermore, these therapies are of limited value in patients with a desire to become pregnant because they inhibit ovulation. An important target for current research is to identify effective therapies that can be safely administered in the long term. GnRH analogues with add-back therapy, progestogens and continuous oral contraceptive are options available for a medium or long-term systemic treatment. Mifepristone, an antiprogestogen, may constitute an alternative if encouraging preliminary data on its effectiveness and tolerability are confirmed. A very appealing area of interest is the possibility of treating endometriosis without suppressing ovarian function. Aromatase inhibitors might have such characteristics as they have been shown to inhibit oestrogen production selectively in endometriotic lesions, without affecting ovarian function; the clinical role of these drugs in the treatment of endometriosis is under evaluation. Levonorgestrel medicated intrauterine device has proven effective in relieving dysmenorrhoea associated with endometriosis, as well as pain associated with rectovaginal endometriosis. Although a systemic absorption is present determining side effects, this approach is promising in the long-term management of this condition. A fundamental objective of research in endometriosis treatment is to develop new therapeutic approaches based on the findings from experimental studies on the aetiopathogenesis of the disease; current research is focusing on anti-inflammatory drugs and modulators of the immune system. TNF-binding protein-1 and IL-12 have proved effective in reducing endometriotic lesions in animal models, while pentoxifylline and INF-alpha 2b have shown encouraging results in clinical studies. This area may be of paramount importance in the near future in order to develop a therapy that could prevent or eradicate endometriosis rather than merely relieving the symptoms.

-----

IDrugs. 2004 May;7(5):451-63.
Medical management of endometriosis: a systematic review.
Schroder AK, Diedrich K, Ludwig M.
University Schleswig-Holstein, Department of Gynecology and Obstetrics, University Clinic Hospital, Campus Lubeck, Ratzeburger Allee 160, 23538 Lubeck, Germany. Annika_Schroeder@web.de

Endometriosis is an important clinical problem in routine practice. Besides the problems of dysmenorrhea, dyspareunia and chronic abdominal pain, women with endometriosis are often infertile. We performed a systematic literature review on two issues: firstly, we clarified which medical treatment options have been investigated in prospective, randomized studies. Secondly, potential future treatments, still being preclinically investigated, were examined. A meta-analysis was not possible as the studies varied too much in their protocols and inclusion and exclusion criteria, as well as in the drugs and doses administered. Gonadotropin-releasing hormone (GnRH) agonists, progestins and oral contraceptives all appear to offer certain advantages for endometriosis patients. GnRH agonists appear to be the most effective but they are expensive and long-term treatment is not possible because of loss of bone mineral density. Estrogen add-back may offer some benefit for the clinical complaints of patients, but it may reduce the efficacy of GnRH agonists. Progestins have the best clinical profile and a good cost-effectiveness balance; however, most studies found that they were not as effective as GnRH agonists. Oral contraceptives are only effective during treatment and have a high relapse rate after therapy is completed. Future options may include the use of GnRH agonists, selective estrogen receptor modulators (SERMs) and anti-estrogens, as well as immunomodulators.

-----

Best Pract Res Clin Obstet Gynaecol. 2004 Apr;18(2):329-48.
Surgical management of endometriosis.
Donnez J, Pirard C, Smets M, Jadoul P, Squifflet J.
Department of Gynecology, Universite Catholique de Louvain, Cliniques Universitaires St-Luc, avenue Hippocrate 10, 1200 Brussels, Belgium.

The efficacy of medical and surgical treatment of endometriosis-associated infertility and pelvic pain is a source of ongoing controversy. Complete resolution of endometriosis is not yet possible and current therapy has three main objectives: (1) to reduce pain; (2) to increase the possibility of pregnancy; and (3) to delay recurrence for as long as possible. It is possible that a consensus will never be reached on the optimal treatment of minimal and mild endometriosis. In case of moderate and severe endometriosis-associated infertility, the combined approach (operative laparoscopy with a gonadotropin-releasing hormone (GnRH) agonist) should be considered as 'first-line' treatment. The mean pregnancy rate of 50% reported in the literature following surgery provides scientific proof that operative treatment should first be undertaken to give our patients the best chance of conceiving naturally. In case of rectovaginal adenomyotic nodules, surgery must be considered as first-line therapy, medical therapy being relatively inefficacious.

-----

Am J Obstet Gynecol. 2004 Apr;190(4):1020-4.
Long-term follow-up after conservative surgery for rectovaginal endometriosis.
Fedele L, Bianchi S, Zanconato G, Bettoni G, Gotsch F.
Clinica Ostetrico-Ginecologica dell' Universita di Milano, Ospedale San Paolo, Istituto Ostetrico-Ginecologico "Luigi Mangiagalli," Milano, and Clinica Ostetrico-Ginecologica dell'Universita di Verona, Policlinico Borgoroma, Verona, Italy.

OBJECTIVE: The purpose of this study was to evaluate long-term results in patients who received conservative surgical treatment for rectovaginal endometriosis.Study design We analyzed the follow-up data for 83 women who underwent surgery for rectovaginal endometriosis. The inclusion criteria were age 20 to 42 years, moderate-to-severe pain symptoms, conservative treatment with retention of the uterus, and at least 1 ovary; the follow-up period was >/=12 months. Kaplan-Meier analysis and Cox regression were used to calculate recurrence rates. RESULTS: The cumulative rates of pain recurrence, clinical or sonographic recurrence, and new treatment were 28%, 34%, and 27%, respectively. The younger patients had the higher risk of recurrence. Pregnancy had protective effects against the recurrence of symptoms and a need for a new treatment. Patients who underwent bowel resection had fewer recurrences. CONCLUSION: Segmental resection and anastomosis of the bowel, when necessary, improves the outcome without affecting chances of conception. Higher recurrence rates in younger patients seems to justify a more radical treatment in this group of women.

-----

Hum Reprod. 2004 Apr 22 [Epub ahead of print]
One year comparison between two add-back therapies in patients treated with a GnRH agonist for symptomatic endometriosis: a randomized double-blind trial.
Fernandez H, Lucas C, Hedon B, Meyer JL, Mayenga JM, Roux C.
Service de Gynecologie-Obstetrique, Hopital Antoine Beclere, AP-HP, 92141 Clamart, France.

BACKGROUND: It has been proposed that hormonal supplementation during prolonged GnRH agonist therapy prevents hypoestrogenic side effects, including bone loss. The optimal combination for long-term treatments with safe metabolic profile remains questionable. A norprogesterone derivative, promegestone, was assessed for the first time in a double-blind trial. METHODS: Seventy-eight patients with endometriosis with rAFS (Revised American Society for Reproductive Medicine) scores of III-IV were randomly assigned to monthly leuprorelin 3.75 mg (1 year) which, after the third injection was used in combination with promegestone 0.5 mg (P) plus either estradiol placebo (PL) or estradiol 2 mg (E) per day. Bone mineral density (BMD) was determined at baseline, 6 and 12 months, and biological and clinical quarterly assessments were performed. Analysis was by the intention to treat method. RESULTS: At month 12, BMD changes from baseline were -6.1 +/- 3.7 and -4.9 +/- 4.0% in the PL-P group, at the spine and hip, respectively. This bone loss was prevented in the E-P group: -1.9 +/- 3.1 and -1.4 +/- 2.3%, respectively (P < 0.0001 inter-group comparisons). The BMD decrease in the E-P group was explained by the changes occurring during the first 6 months of treatment. There was no deleterious change in lipid parameters. Clinical improvement was observed without an inter-group difference. CONCLUSIONS: Estradiol 2 mg and promegestone 0.5 mg per day is an effective and safe add-back therapy, which can be proposed for prolonged leuprorelin treatment over 6 months in severe endometriosis.

-----

BJOG. 2004 Apr;111(4):353-6.
Pain, quality of life and complications following the radical resection of rectovaginal endometriosis.
Ford J, English J, Miles WA, Giannopoulos T.
Department of Obstetrics and Gynaecology, Worthing and Southlands Hospitals Trust, UK Department of Surgery, Worthing and Southlands Hospitals NHS Trust, UK.

OBJECTIVE: To determine the long term response, quality of life and levels of pain following the radical excision of rectovaginal endometriosis. DESIGN: A cohort study. SETTING: A tertiary referral centre for the management of advanced endometriosis. SAMPLE: All patients who had undergone radical resection. METHODS: Case note review and patient questionnaire. MAIN OUTCOME MEASURES: Surgical complications. Overall improvement. Dysmenorrhoea, dyspareunia, dyschezia and chronic pain were measured using a visual analogue scale. Quality of life was measured using the EQ-5D questionnaire. RESULTS: Twelve radical resections were performed by laparotomy, 48 by laparoscopy. Ten patients had a hysterectomy. Forty-eight patients underwent shaving of the pre-rectal fascia, two had a disc resection of the rectum, 10 had an anterior rectal resection. Two patients required a colostomy and two needed subsequent dilation of a stenosed anastomosis. Forty-four of the first 46 patients replied. The median follow up period was 12 months (range 2 to 22 months) and 86% (38/44) reported an improvement or whom 27 (61%) had a good response (pain completely gone or greatly improved). Patients having a hysterectomy or a disc or segmental resection of the rectum reported a good response and had a normal quality of life. Quality of life scores in the study group overall were lower than the background population. CONCLUSIONS: Radical resection is an effective treatment for rectovaginal endometriosis. Hysterectomy and rectal resection were associated with a better response and quality of life.

-----

Fertil Steril. 2004 Feb;81(2):290-6.
Treatment of endometriosis and chronic pelvic pain with letrozole and norethindrone acetate:
a pilot study.
Ailawadi RK, Jobanputra S, Kataria M, Gurates B, Bulun SE.
Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, Illinois, USA.

OBJECTIVE: To determine the role of an aromatase inhibitor, letrozole, in the treatment of reproductive-age women with endometriosis and associated chronic pelvic pain. DESIGN: Phase 2, open-label, nonrandomized proof-of-concept study. SETTING: Outpatient tertiary-care center. PATIENT(S): Ten patients with endometriosis, all previously treated both medically and surgically, with unsatisfactory results. INTERVENTION(S): Endometriosis was diagnosed by biopsy and scored from an initial diagnostic laparoscopy performed within 1 month before treatment was begun. Oral administration of letrozole (2.5 mg), the progestin norethindrone acetate (2.5 mg), calcium citrate (1,250 mg), and vitamin D (800 IU) was done daily for 6 months. Within 1-2 months after completion of the treatment, a second-look laparoscopy was performed to score and biopsy endometriosis. MAIN OUTCOME MEASURE(S): Changes in American Society for Reproductive Medicine (ASRM) scores for endometriosis, pelvic pain assessed by visual analog scale, serum hormone levels (FSH, LH, E(2), and estrone [E(1)]), and bone density (DEXA scan). RESULT(S): No histologically demonstrable endometriosis was present in any patient during the second-look laparoscopy. ASRM and pelvic pain scores decreased significantly in response to treatment. Overall, no significant change in bone density was detected. Gonadotropin levels were not significantly altered by treatment, and although circulating E(2) and E(1) levels were reduced, the decrease was not statistically significant. CONCLUSION(S): The combination of letrozole and norethindrone acetate achieved marked reduction of laparoscopically visible and histologically confirmed endometriosis in all 10 patients and significant pain relief in nine out of 10 patients who had not responded previously to currently available treatments. On this basis, letrozole should be a candidate for the medical management of endometriosis.

-----

JSLS. 2004 Jan-Mar;8(1):3-7.
Laparoscopic ureteroneocystostomy and vesicopsoas hitch for infiltrative endometriosis.
Nezhat CH, Malik S, Nezhat F, Nezhat C.
Nezhat Medical Center, Atlanta, Georgia 30342, USA. info@nezhat.com

OBJECTIVE: To report a series of laparoscopic vesicopsoas hitch procedures performed for the treatment of infiltrative ureteral endometriosis. METHODS: A retrospective chart review of 6 women with severe endometriosis and ureteral obstruction caused by infiltrative disease of the distal ureter was performed. The patients underwent successful laparoscopic ureteroneocystostomy and vesicopsoas hitch. RESULTS: Five of the 6 patients had a history of endometriosis, and their obstructions were diagnosed during prior surgeries. The other patient was diagnosed with severe endometriosis of the rectum, bladder, and ureter at the time of the procedure. She was referred for evaluation of an incidental finding of hydroureter and hydronephrosis. Three patients were treated with gonadotrophin-releasing hormone (GnRH) analog for at least 3 months preoperatively. Five patients had ureteral stents in place prior to the psoas hitch surgery. No intra- or postoperative complications occurred. All patients had a normal cystogram performed 10 to 14 days postoperatively prior to Foley catheter removal. Stents were kept in place for 6 to 8 weeks, and an intravenous pyelogram (IVP) was done 2 weeks after removal. All patients had a normal renal ultrasound, computer tomography, or intravenous pyelogram at least 1 year postoperatively. CONCLUSION: Laparoscopic vesicopsoas hitch can be a safe and effective alternative to the laparotomy with the known benefits of laparoscopy.

-----

Hum Reprod. 2004 Jan;19(1):179-84.
The evaluation of the effectiveness of an intrauterine-administered progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease.
Lockhat FB, Emembolu JO, Konje JC.
Department of Obstetrics and Gynaecology, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK.

BACKGROUND: Medical treatment of endometriosis, a condition which significantly affects the quality of life in approximately 10-15% of women in the reproductive years, remains problematic. Although oral progestogens are effective and cheap, their efficacy is significantly influenced by poor compliance and systemic side effects. A progestogen (levonorgestrel) administered via an intrauterine system (Lng-IUS) has been demonstrated to improve symptoms of endometriosis; however, its effect on the staging of the disease has not been evaluated. The aims of this study were therefore to investigate the effectiveness of Lng-IUS in the symptomatic relief of minimal to moderate endometriosis and in the staging of the disease. METHODS: This was a prospective non-comparative observational study in which 34 women with clinically suspected and laparoscopically confirmed symptomatic minimal to moderate endometriosis had Lng-IUS inserted for 6 months. The symptom profile and stage of the disease before, during and after 6 months of treatment and patients' satisfaction with treatment and willingness to retain the device at the end of the study period were used to assess response to treatment. RESULTS: Of the 34 women recruited, 29 (85%) completed the study; five discontinued, for personal reasons (one), side effects of worsening of acne (one) and lower abdominal/ pelvic pain (three). Significant (P<0.05) improvements in severity and frequency of pain and menstrual symptoms as well as staging were achieved, with 68% (23) of cases electing to continue with the device after 6 months of therapy. CONCLUSION: The levonorgestrel intrauterine system is an effective hormonal option for treating symptomatic endometriosis (minimal to moderate). It also alters the American Fertility Society staging of disease. With a continuation rate of 68% after 6 months, it has the potential for providing long-term therapy in a substantial number of sufferers, although this would require further study and verification.

-----

J Gynecol Obstet Biol Reprod (Paris). 2003 Dec;32(8 Pt 2):S42-4.
[Ovarian stimulation and endometriosis]
[Article in French]
Devroey P.
Service de Gynecologie-Obstetrique, Bruxelles, Belgique.

Controversies concerning the optimal treatment of endometriosis and its related infertility still exist, and few comparative studies are available. The number of oocytes retrieved and pregnancy rates seem to be higher after in vitro fertilization that follows long-term down-regulation with Gn-RH agonists, but the available studies are retrospective and do not allow definitive conclusion. No comparative studies are available between extra long and short Gn-RH agonist in women affected by endometriosis. No benefit of the use of danazol has been demonstrated in this indication. There are no data available on Gn-RH antagonist pretreatment before ovarian stimulation in patients with endometriosis undergoing assisted reproduction techniques. Endometrioma resection prior to IVF may compromise or destroy adjacent normal ovarian cortex and thus might reduce the ovarian reserve. Aspiration of endometrioma is associated with an increased risk of infection.

-----

J Gynecol Obstet Biol Reprod (Paris). 2003 Dec;32(8 Pt 2):S32-6.
[Chronic pelvic pain and endometriosis]
[Article in French]
Chapron C; D'apres la communication de.
Service de Gynecologie-Obstetrique et de Medecine de la Reproduction, Hopital Cochin, Paris, France.

Chronic pelvic pain and endometriosis remain two of the most perplexing problems in gynaecology. In some women, the problem is to determine whether or not endometriosis causes the pain they are consulting for. Deep pelvic endometriosis presents essentially in the form of a painful syndrome dominated by deep dyspareunia and painful functional symptoms that recur according to the menstrual cycle. The semiology is directly correlated with the location of the lesions (bladder, rectum). Lesions of the utero-sacral ligaments are the most frequent deeply infiltrating endometriosis lesions. The following variables are related to the severity of dysmenorrhoea: number of previous surgical procedures for endometriosis, score in the revised American Fertility Society classification, extensiveness of adnexal adhesion, Douglas obliteration, size of the posterior deeply infiltrating endometriosis implant, extent of the sub-peritoneal infiltration by the posterior deeply infiltrating endometriosis. It is essential to investigate (clinically and with magnetic resonance imaging) these deep endometriosis lesions and to draw up a precise map, which is the only way to be sure that exeresis will be complete. Surgery remains the first intention treatment, whereas medical treatment is only palliative in the majority of cases. Success of treatment depends on how radical surgical exeresis is. Operative laparoscopy is efficient for bladder, utero-sacral ligaments and vaginal deeply infiltrating endometriosis. However, indications for laparotomy still exist, notably for bowel lesions. Based on analysis of the anatomical distribution of deep pelvic endometriosis lesions, a "surgical classification" is proposed with the aim of establishing standard modes for surgical treatment. Further studies are required to clarify the place and modes for pre- and postoperative medical treatment.

-----

J Gynecol Obstet Biol Reprod (Paris). 2003 Dec;32(8 Pt 2):S20-2.
[Surgical treatment for endometriomas]
[Article in French]
Dubuisson JB.
Service de Gynecologie-Obstetrique et de Medecine de la Reproduction, Hopital Cochin, Paris, France.

Endovaginal ultrasonography is relevant for the diagnosis of ovarian endometriomas with a good predictive value. Magnetic resonance imaging (MRI) may be recommended if deep endometriosis is suspected. Operative laparoscopic management is the 'gold standard' for surgical treatment, and medical treatment should not be given before surgery. Peritoneal lavage cytology must be performed before cystectomy. First, the cyst is opened and the endometriosic fluid is aspirated. The stripping technique is performed and after hemostasis, the ovarian cortex is reattached with microsurgical sutures. Coagulation or laser vaporization of endometriomas without excision of the pseudocapsule seems to be associated with a significant increase in risk of cyst recurrence. Recurrent ovarian surgery is not recommended in women with infertility, as it might be deleterious for ovarian reserve.

-----

J Gynecol Obstet Biol Reprod (Paris). 2003 Dec;32(8 Pt 2):S11-4.
[Pathophysiology, symptomatology and therapeutic management of stage I and II endometriosis]
[Article in French]
Nisolle M, Nervo P.
Service de Gynecologie-Obstetrique, Universite de Liege, Belgique.

Stage I and II endometriosis is defined by a r-AFS score respectively ranging from 1 to 5 and from 6 to 15. This mild, superficial endometriosis is a very common pathology occurring in infertile women. Nevertheless, these women with stage I/II endometriosis have usually few pelvic pain. This review summarizes the recent literature concerning new data on the pathogenesis of peritoneal endometriosis and its clinical management. Retrograde menstruation, peritoneal adhesion of shed endometrial tissue, and outgrowth of endometrial cells, glands and stroma, are essential elements in the pathogenesis of endometriosis according to Sampson's classic implantation theory. Nevertheless, exact pathophysiology of endometriosis remains unknown. Superficial endometriotic lesions observed by laparoscopy have to be treated. Surgical procedure is not difficult for stage I and II of endometriosis. Surgical procedure remains controversial. Carbon dioxide (CO2) Laser can be used for laparoscopic destruction of endometriosis. Newer procedures, such as SurgiTouch (Lumenis), are more effective in vaporization and decrease the risk thermal damage of contiguous structures. The monopolar scissors can also be used in order to excise the peritoneal endometriotic lesions. Medical treatment may be usefull if surgical treatment is not complete or if the pelvic cavity is hypervascularized. In these cases, Gonadotropin-Releasing Hormone agonists (Gn-RHa) are the most common and effective treatment.;

-----

J Gynecol Obstet Biol Reprod (Paris). 2003 Dec;32(8 Pt 2):S15-9.
[Pathophysiology, symptomatology and therapeutic management of stage III and IV endometriosis]
[Article in French]
Audebert A.

Stage III endometriosis is defined by a r-AFS score respectively ranging from 16 to 40 and stage IV over 40. Deep pelvic endometriosis presents essentially in the form of a painful syndrome dominated by chronic pelvic painful, dysmenorrhea and deep dyspareunia. Pathophysiology of pelvic pain associated with endometriosis remains unknown. In the literature, correlation between extension of the endometriosis and severity of the painful remains controversies. Contraception by levonorgestrel-releasing intra-uterine systems appears to decrease pain related to deeply infiltrating endometriosis. Surgery by laparoscopy remains the first intention treatment when infertility is associated with endometriosis, whereas medical treatment is only palliative in the majority of cases. Success of treatment depends on how radical surgical exeresis is. Spontaneous pregnancy rates are significantly increased after surgical treatment. Recurrent ovarian surgery is not recommended in women with infertility, as it might be deleterious for ovarian reserve. Medical treatment using Gn-RH agonists is indicated when recurrence occurs after surgery.

-----

Appl Psychophysiol Biofeedback. 2003 Dec;28(4):279-89.
The use of thermal biofeedback in the treatment of pain associated with endometriosis:
preliminary findings.
Hawkins RS, Hart AD.
Graduate School of Psychology, Fuller Theological Seminary, Pasadena, California, USA. drrebeccahawkins@hotmail.com

Endometriosis is a common gynecological disease that causes marked physical and emotional distress in lives of women, resulting in dysmenorrhea, pain, or both throughout the menstrual cycle in over 96% of cases. A multiple case study design (N = 5) was employed to investigate the use of thermal biofeedback in the treatment of pain associated with endometriosis. The majority of participants (4 out of 5) were able to demonstrate mastery over hand temperature through thermal biofeedback. Of those participants, significant reductions in various aspects of pain were observed by the end of the study; one had a significant increase in Life Control; two had reductions in Pain Severity; three had a decrease in Affective Distress; and all 4 demonstrated reduction in Life Interference, as measured by the West Haven-Yale Multidimensional Pain Inventory. This is a preliminary study with a small sample size and without a control sample; hence, the results are considered only as suggestive of the potential use of biofeedback therapy in alleviating pain and associated symptomatology related to endometriosis. Further research is warranted.

-----

Ann N Y Acad Sci. 2003 Nov;997:247-54.
Endometriosis and reproductive disorders.
Elsheikh A, Milingos S, Loutradis D, Kallipolitis G, Michalas S.
1 Department of Obstetrics and Gynecology, University of Athens, Alexandra University Hospital, Athens, Greece.

The classic concept of endometriosis as a cause of infertility is challenged. Traditionally, both surgical and medical therapy have focused on alleviation of symptoms, prevention of disease progression, and promotion of fertility. In spite of significant developments in medical and surgical approaches, the optimal therapy for treating endometriosis-associated infertility has yet to be established. The relationship between prevalence of fecundity and stage of the disease was studied according to the type of management. Of 151 women who were consecutively proved by laparoscopy to have endometriosis stage I and II, operative laparoscopy was performed in 49, medical treatment in 59, and expectant management in 43 cases. During a 24-month period, the cumulative pregnancy rates were 36.7%, 30.5%, and 20.9%, respectively. Survival analysis over the 20 weeks of pregnancy showed that the probability of carrying the pregnancy beyond this week was 30.6%, 25.4%, and 16.2%, respectively. Of 64 patients with advanced disease, 34 (53%) became pregnant during the 2-year follow-up period. A significantly increased pregnancy rate was found for the first year as compared to the second (76% vs. 24%). The existence of adhesions affected adversely the outcome of the treatment when early achievement of pregnancy is considered. Diagnosis and treatment of endometriosis was beneficial for the infertile women. Laparoscopic surgery seems to be the best treatment in these cases, as it increases the fecundity and involves minimal risk.

-----

Ann N Y Acad Sci. 2003 Nov;997:240-6.
Evaluation of the role of laser treatment for the treatment of pain in endometriosis.
Shaw RW.
Academic Division of Obstetrics Gynaecology, School of Human Development, University of Nottingham, Derby City General Hospital, Uttoxeter Road, Derby, UK.

There have been few appropriately conducted trials to evaluate the effectiveness of laser destruction of endometriosis in relieving pain symptoms, yet the techniques are increasingly being used. Laser destruction has been shown to be more effective than the placebo effect of laparoscopy alone in one trial, at least at 6-month follow-up. Longer-term studies suggest increasing recurrence of symptoms with time [23% at 12 months in one study, and 44% by a mean of 19.7 months (5-60) follow-up]. These recurrence rates are similar to those seen following 6 months medical treatment. It is unknown whether laparoscopic uter-sacral nerve ablation (LVNA) in addition to destrution of lesions will produce better results, and appropriate trials are needed in several areas to determine the role of laser therapy.

-----

Steroids. 2003 Nov;68(10-13):1019-32.
Asoprisnil (J867): a selective progesterone receptor modulator for gynecological therapy.
DeManno D, Elger W, Garg R, Lee R, Schneider B, Hess-Stumpp H, Schubert G, Chwalisz K.
TAP Pharmaceutical Products Inc., 675 N. Field Drive, 600452, Lake Forest, IL, USA

Asoprisnil is a novel selective steroid receptor modulator that shows unique pharmacodynamic effects in animal models and humans. Asoprisnil, its major metabolite J912, and structurally related compounds represent a new class of progesterone receptor (PR) ligands that exhibit partial agonist and antagonist activities in vivo. Asoprisnil demonstrates a high degree of receptor and tissue selectivity, with high-binding affinity for PR, moderate affinity for glucocorticoid receptor (GR), low affinity for androgen receptor (AR), and no binding affinity for estrogen or mineralocorticoid receptors. In the rabbit endometrium, both asoprisnil and J912 induce partial agonist and antagonist effects. Asoprisnil induces mucification of the guinea pig vagina and has pronounced anti-uterotrophic effects in normal and ovariectomized guinea pigs. Unlike antiprogestins, asoprisnil shows only marginal labor-inducing activity during mid-pregnancy and is completely ineffective in inducing preterm parturition in the guinea pig. Asoprisnil exhibits only marginal antiglucocorticoid activity in transactivation in vitro assays and animal models. In male rats, asoprisnil showed weak androgenic and anti-androgenic properties. In toxicological studies in female cynomolgus monkeys, asoprisnil treatment abolished menstrual cyclicity and endometrial atrophy. Early clinical studies of asoprisnil in normal volunteers demonstrated a dose-dependent suppression of menstruation irrespective of the effects on ovulation, with no change in basal estrogen concentrations and no antiglucocorticoid effects. Unlike progestins, asoprisnil does not induce breakthrough bleeding. With favorable safety and tolerability profiles thus far, asoprisnil appears promising as a novel treatment of gynecological disorders, such as uterine fibroids and endometriosis.

-----

Ann N Y Acad Sci. 2003 Nov;997:269-273.
Laparoscopic Management of Patients with Endometriosis and Chronic Pelvic Pain.
Milingos S, Protopapas A, Drakakis P, Liapi A, Loutradis D, Kallipolitis G, Milingos D, Michalas S.
1 Department of Obstetrics and Gynecology, University of Athens, "Alexandra" Maternity Hospital, 115 28 Athens, Greece.

Endometriosis has been traditionally included among the most important causes of chronic pelvic pain (CPP) in women of reproductive age. The main clinical manifestations of endometriosis are dysmenorrhea, dyspareunia, and chronic nonmenstrual pain. Despite the high prevalence of endometriosis in women suffering from CPP, controversy still exists regarding the true association between the stage and extent of this peculiar disease and the severity of pain. Over the last decade, advances in endoscopic technology have enabled gynecologic surgeons to recognize many atypical appearances of the endometriotic implants not known to exist before, thus allowing their complete excision or destruction. Laparoscopic surgery may offer considerable relief in patients with endometriosis and CPP. Although cases with advanced endometriosis seem to benefit the most, we also support surgical treatment in patients with early endometriosis diagnosed using laparoscopy, as many will experience improvement in their symptoms.

-----

Ann N Y Acad Sci. 2003 Nov;997:229-239.
Endometriosis: Treatment Strategies.
Valle RF, Sciarra JJ.
Department of Obstetrics and Gynecology, Northwestern University Medical School, Chicago, Illinois 60611, USA.

Endometriosis is often a perplexing medical condition for both the physician and the patient. Accordingly, development of treatment strategies based on the needs of the individual patient is highly desirable. Although endometriosis has been part of the clinical practice for almost a century, many questions remain relating to the relationship between endometriosis and infertility as well as endometriosis and pelvic pain. Endometriosis is a disease of reproductive-age women, and it is now well recognized that a genetic susceptibility appears probable. The prevalence in the general population has never been clearly established. Factors to consider in management include the age and reproductive desires of the patient, the stage of the disease, and, most importantly, the symptoms. Therapeutic options include no treatment, medical therapy, surgery, or combination therapy. Oral contraceptives, androgenic agents, progestins, and gonadotropin releasing hormone (GnRH) analogs have all been used successfully, although at the present time, the latter preparations are the most popular medical therapy for endometriosis. Leuprolide acetate, goserelin acetate, and nafarelin acetate are all effective agents. Surgical therapy is appropriate, especially for advanced stages of the disease. Laparoscopy is an effective surgical approach with the goal of excision of visible endometriosis in a hemostatic fashion. Since endometriosis is a chronic condition, it is not uncommon for recurrences to occur. While endometriosis remains an enigmatic disease, the introduction of new pharmacologic agents, such as GnRH analogs and newer endoscopic methods of surgical treatment, have facilitated and improved the overall management of this disease.

-----

Steroids. 2003 Nov;68(10-13):981-93.
Progesterone antagonists and progesterone receptor modulators: an overview.
Spitz IM.
Institute of Hormone Research, Shaare Zedek Medical Center, P.O. Box 3235, 91031, Jerusalem, Israel

Since the original description of the structure of the antiprogestin, mifepristone, was published, numerous related compounds have been synthesized which may function as progesterone antagonists (PAs) or progesterone receptor modulators (PRMs). The latter are mixed agonists-antagonists. Both PAs and PRMs have therapeutic applications in female health care. Mifepristone is predominantly a PA and displays only minimum agonist activity in certain systems. Together with a prostaglandin, mifepristone can terminate pregnancies of less than 9 weeks duration, and it may also be used at later gestational ages. Mifepristone causes expulsion of the uterine contents following intrauterine fetal death. A mifepristone-prostaglandin combination has been shown to be very effective treatment in women with menses delay of 11 days or less. Many PAs and PRMs display antiproliferative effects in the endometrium. Serum estradiol levels however remain in the early to mid-follicular phase range. For this reason, they have application in the treatment of endometriosis and myoma without being associated with bone loss and hypoestrogenism. PRMs may also find application in the treatment of dysfunctional bleeding as well as an adjunct to estrogens in hormone replacement therapy in postmenopausal women. Many PAs have contraceptive potential by suppressing follicular development and blocking the LH surge. Low doses may also be potential contraceptives by retarding endometrial maturation without affecting ovulation or inducing bleeding. Mifepristone is an excellent agent for use as an emergency "postcoital" contraceptive. PAs may also be useful in IVF programs to prevent a premature LH surge and to delay the emergence of the implantation window. In addition to their use in women's health care, mifepristone and several other PAs are potent antiglucocorticoid agents and may be used to treat ACTH-independent Cushing's syndrome. They may also be used in the treatment of tumors containing steroid receptors and in other situations which require suppression of the ACTH-cortisol axis.

-----

Curr Opin Investig Drugs. 2003 Oct;4(10):1209-12.
Use of estrogen antagonists and aromatase inhibitors in endometriosis.
Vigano P, Mangioni S, Odorizzi MP, Chiodini A, Rocca S, Chiodo I.
II Department of Obstetrics and Gynecology, University of Milano, Via Commenda 12, 20122 Milano, Italy. paola.vigano@unimi.it

Endometriosis is an estrogen-dependent disorder mostly occurring in reproductive-age women. Various therapies have been used in an attempt to treat endometriosis, including ovarian suppression therapy, surgical treatment or a combination of these strategies. However, in general, substantial surgery remains the primary treatment option for endometriosis at all stages. Recently, aromatase inhibitors and anti-estrogens have been proposed as novel potential candidates. The rationale for the use of aromatase inhibitors is mostly related to the high aromatase expression in endometriotic cysts and extra-ovarian endometriotic implants. Among anti-estrogens, raloxifene has been investigated in animal models with good results, but in premenopausal women, the compound does not seem to suppress estrogen production.

-----

Surgery. 2003 Oct;134(4):549-52; discussion 552-4.
Utility of laparoscopy in chronic abdominal pain.
Onders RP, Mittendorf EA.
Department of Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5047, USA.

BACKGROUND: Patients with chronic abdominal pain can undergo numerous diagnostic tests with little change in their pain. This study was undertaken to assess the utility of performing diagnostic and therapeutic laparoscopy in patients with chronic abdominal pain for longer than 12 weeks. METHODS: All patients undergoing laparoscopy by the primary author were prospectively entered into a database for the 3-year period July 1, 1997 through June 30, 2000. The patients' demographic data, length of time with pain, number of diagnostic studies performed before surgery, intraoperative findings, interventions, pathology, and long-term follow-up were determined. RESULTS: A total of 70 patients (61 women and 9 men) with an average age of 42 years, underwent diagnostic laparoscopy only for the evaluation and treatment of chronic abdominal pain. The average length of time with pain was 74 weeks (range 12-260) and the average number of studies performed prior to surgical referral was 3.3. Fifty-three (76%) patients had their procedures performed as outpatients, with the remainder admitted for observation status. The average length of operative time was 70 minutes; no cases required conversion to an open procedure and no complications occurred. Findings included adhesions in 39, a hernia in 13, adhesions from the appendix to adjacent structures in 6, appendiceal pathology in 5, endometriosis in 3, and gallbladder pathology in 2. Ten patients had no obvious pathology. At the time of their initial postoperative visit, 90% reported their pain to be gone or improved. After an average follow-up of 129 weeks, 71.4% had long-term pain relief. All patients with recurrence of pain had it within the first 6 months. No patient experienced any long-term complications and all reported satisfaction with their procedure. CONCLUSIONS: Laparoscopy has a significant diagnostic and therapeutic role in patients with chronic pain. Therapeutic laparoscopy studies have to follow-up with patients at least 6 months. With aggressive indicated therapeutic laparoscopy, including adhesiolysis, appendectomy, cholecystectomy, or hernia repairs, more than 70% of patients can have improvement in their pain.

-----

Zentralbl Gynakol. 2003 Jul-Aug;125(7-8):267-75.
[GnRH agonist and add back therapy--indications, results and problems in the treatment of genital endometriosis]
[Article in German]
Mettler L.
Universitatsklinikum Schleswig-Holstein, Campus Kiel, Klinik fur Gynakologie und Geburtshilfe und Michaelis-Hebammenschule.

It was the aim of this paper to assess whether GnRH agonist and add-back therapy is an important post operative and long-term therapeutical supplement in the treatment of genital endometriosis, especially in cases of chronic pain. Although its effectiveness with regard to the relief of pain is not better than other therapeutical options, the spectrum of side effects is acceptable. Un-desired side effects of GnRH agonists are reversible and can be minimised under the synchronised application of an add-back therapy. In patients with symptomatic endometriosis the effectiveness of GnRH agonist therapy can remain and simultaneously the hypoestrogenic side-effects can be covered by the appropriate add-back therapy. In our investigations a useful combination treatment of leuprolide acetate depot (3.75 mg per month) and tibolone (2.5 mg per day) over a period of 3-6 months was found.The analyses of Hornstein et al. 1998 and Surrey et al. 2002 clearly demonstrate that a significant reduction in pain with few side effects results when from the first day of treatment with leuprolide acetate depot an add-back scheme of 5 mg norethindrone acetate per day is applied.

-----

Zentralbl Gynakol. 2003 Jul-Aug;125(7-8):259-66.
[Laparoscopic therapy of intestinal endometriosis and the ranking of drug treatment]
[Article in German]
Keckstein J, Ulrich U, Kandolf O, Wiesinger H, Wustlich M.
Abteilung fur Gynakologie und Geburtshilfe, Landeskrankenhaus Villach, Karnten. joerg.keckstein@lkh-vil.or.at

Patients with severe endometriosis involving the rectovaginal septum and bowel makes surgery necessary. The laparoscopic approach offers the possibility to perform the complete resection with minimal invasive techniques. Small lesions can be removed by full-thickness-resection. Large nodules make a segmental resection necessary. Deep lesions are resected with stapling devices. Nodules in the sigmoid ore removed by laparoscopic assisted hand-sewn anastomosis. RESULTS: Between 3/96 and 7/03 142 patients with severe endometriosis involving the bowel have been treated laparoscopically. The pre-operative complains have been reduced as following: dyschezio: 88%, dyspareunia 87%, chronic pelvic pain 96%, disturbance of sexuality 75%. The complication rate was minimal: leakage of the anastomosis n=4 (2.8%), paraproctial abscess 2 (1.4%), blood transfusion 1 (0,7 %), severe stenosis of the anastomosis 6 (4.2%). CONCLUSION: Laparoscopic approach is a safe and effective technique to treat deep infiltrating endometriosis with bowel involvement. The hormonal treatment of bowel endometriosis is used in patients with minimal symptoms. The postoperative treatment becomes necessary in incomplete operations or in patients with severe adenomyosis and infertility.

-----

Fertil Steril. 2003 Aug;80(2):305-9.
Comparison of a levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study.
Vercellini P, Frontino G, De Giorgi O, Aimi G, Zaina B, Crosignani PG.
Clinica Ostetrica e Ginecologica I, Istituto "Luigi Mangiagalli", University of Milano, Milan, Italy. paola.vercellini@unimi.it

OBJECTIVE: To determine whether the frequency and severity of dysmenorrhea are reduced in women with symptomatic endometriosis in whom a levonorgestrel-releasing intrauterine device (Lng-IUD) is inserted after operative laparoscopy compared with those treated with surgery only. DESIGN: Open-label, parallel-group, randomized, controlled trial. SETTING: A tertiary care and referral center for patients with endometriosis. PATIENTS(S): Parous women with moderate or severe dysmenorrhea undergoing first-line operative laparoscopy for symptomatic endometriosis. INTERVENTION(S): Randomization to immediate Lng-IUD insertion or expectant management after laparoscopic treatment of endometriotic lesions.Proportions of women with recurrence of moderate or severe dysmenorrhea in the two study groups 1 year after surgery and overall degree of satisfaction with treatment.Moderate or severe dysmenorrhea recurred in 2 of 20 (10%) subjects in the postoperative Lng-IUD group and 9/20 (45%) in the surgery-only group. Thus, a medicated device inserted postoperatively will prevent the recurrence of moderate or severe dysmenorrhea in one out of three patients 1 year after surgery. A total of 15/20 (75%) women in the Lng-IUD group and 10/20 (50%) in the expectant management group were satisfied or very satisfied with the treatment received. CONCLUSION(S): Insertion of an Lng-IUD after laparoscopic surgery for symptomatic endometriosis significantly reduced the medium-term risk of recurrence of moderate or severe dysmenorrhea.

-----

Fertil Steril. 2003 Aug;80(2):300-4.
Gonadotropin-releasing hormone agonist treatment reduced serum interleukin-6 concentrations in patients with ovarian endometriomas.
Iwabe T, Harada T, Sakamoto Y, Iba Y, Horie S, Mitsunari M, Terakawa N.
Department of Obstetrics and Gynecology, Tottori University School of Medicine, Nishimachi, Yonago, Japan. tomio@grape.med.tottorri-u.ac.jp

OBJECTIVE: To determine whether serum interleukin (IL)-6 can be measured in patients with ovarian endometriomas and whether these measurements are useful in managing this disease. DESIGN: A controlled clinical study and an in vitro study. SETTING: Department of Obstetrics and Gynecology, Tottori University, Japan.Twenty-two patients with ovarian endometriomas. INTERVENTION(S): Laparoscopic cystectomy for ovarian endometriomas was performed. Gonadotropin-releasing hormone (GnRH) agonist was administered for 3 months in nine patients before laparoscopic surgery. Endometriotic stromal cells obtained from patients with endometriomas with or without GnRH agonist treatment were cultured. MAIN OUTCOME MEASURES(S): IL-6 concentrations in serum or supernatant of the cell culture were measured using ELISA. RESULTS: The serum concentration of IL-6 in patients with endometriomas was higher at the time of diagnosis than in those without endometriomas. Laparoscopic surgery significantly reduced serum levels of IL-6. Serum IL-6 concentrations also decreased after treatment with GnRH agonist. IL-6 production was attenuated in the endometriotic stromal cells obtained from patients with GnRH agonist treatment compared with patients without such treatment. CONCLUSION(S): GnRH agonist treatment may decrease IL-6 production in endometriotic cells. Measurement of serum IL-6 concentrations may be of value in managing patients with endometriomas.

-----

Obstet Gynecol. 2003 Aug;102(2):397-408.
Evaluation and management of women with endometriosis.
Winkel CA.
Department of Obstetrics and Gynecology, Georgetown University, Washington, DC 20007, USA. winkelc@gunet.georgetown.edu

Endometriosis is a condition that often leads to a variety of symptoms that range from pain complaints to infertility. Endometriosis is also found in women who are asymptomatic. The diagnosis of endometriosis can be made clinically with reliability similar to that of one made surgically. Medical treatment options are effective, as are surgical treatment options. Complications associated with surgery, however, push the balance in favor of medical therapy whenever possible. Based on the body of evidence available at present, women with endometriosis-related complaints should be treated with a first-line medical therapy. If that fails, a second-line medical therapy is warranted under most conditions. Laparoscopic surgery should be reserved for patients in whom second-line medical therapy has failed or is contraindicated by desire to conceive immediately or as soon as possible.

-----

Zentralbl Gynakol. 2003 Jul-Aug;125(7-8):276-80.
[The ranking of the gestagens in the treatment of pain caused by endometriosis—an overview]
[Article in German]
Schweppe KW.
Frauenklinik, Ammerland Klinik GmbH, Akademisches Lehrkrankenhaus der Universitat Gottingen.

Progestins are used for the treatment of endometriosis and endometriosis related complains in low dosages since more than four decades. Progestins induce incomplete regression of endometriotic implants only, they have a high recurrence rate, and they cause side effects--depending of the type of progestin and doses used--therefore GnRH-Agonist induced reversible ovarian suppression has become the standard in medical therapy for endometriosis prior and after surgery during the last ten years. New follow up studies have demonstrated the this new therapeutic principle is associated with relevant recurrence rates also and we have learned, that endometriosis is a chronic disease. For this background a medical therapy, which has low subjective and objective side effects, which can be used repeatedly or over a long time period, and which is cost effective becomes more important. This means that the place of progestins in the treatment of endometriosis has to be defined again and prospective randomised studies with the different substances are necessary.

-----

Obstet Gynecol Clin North Am. 2003 Jun;30(2):379-90.
Adolescent endometriosis.
Attaran M, Gidwani GP.
Section of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. attaram@ccf.org

Endometriosis is a cause of chronic, pelvic pain in adolescents. Lack of response to NSAIDS and OCPs should prompt further investigation and subsequent treatment. The goal of therapy is to minimize pelvic pain and dysmenorrhea primarily through long-term, medical therapy. Surgical intervention is principally indicated to establish a diagnosis. The poor response to surgical therapy negates the need for repetitive or radical surgery. Much patience and care should be directed toward these patients to provide them with an understanding of their disease and to help enhance the quality of their life.

-----

Ceska Gynekol. 2003 Mar;68(2):63-8.
[Long-term follow-up after complete treatment of peritoneal endometriosis with the CO2 laser]
[Article in Czech]
Cibula D, Kuzel D, Fucikova Z, Hill M, Fanta M, Toth D, Jurovich P, Hruskova H, Zivny J.
Gynekologicko-porodnicka klinika 1. LF UK a VFN v Praze, Praha. david.cibula@iol.cz

OBJECTIVE: To evaluate the effect of laparoscopic CO2 laser ablation of peritoneal endometriosis in the treatment of pelvic pain with a long-term follow-up. To differentiate the effect of surgery on different types of pelvic pain. DESIGN: Prospective observational study. SETTING: Department of Obstetrics and Gynecology, 1st Medical Faculty, Charles University and General Faculty Hospital, Prague. METHODS: Patients with 1st to 3rd stage endometriosis, with manifestation of pelvic pain, and with complete excision of peritoneal endometriosis lesions, were included in the study. All visible lesions were vaporized by CO2 laser following adhesiolysis and complete visualization of the pelvis. After the procedure, patients were followed up at 6-month intervals. The severity of pelipathia, dyspareunia, dysmenorrhea, pain during micturition, and pain during defecation were monitored using a visual analog score of 10 points. RESULTS: A total of 31 patients were included in the study. After 6, 12, and 18 months after surgery, the recurrence of pelvic pain was found in 12 (39%), 15 (48%), and 19 (61%) patients, respectively. Improvement or disappearance of complaints was documented 18 months after the surgery in 11 cases of dysmenorrhea (50%), 9 cases of dyspareunia (50%), 14 cases of pelipathia (58%), 12 cases of pain during micturition (71%), and in 14 cases of pain during defecation (87.5%). The proportion of recurrences increases with the length of the interval after the procedure, mainly in dysmenorrhea and dyspareunia. CONCLUSIONS: The effect (improvement or disappearance of pelvic pain) of a complete CO2 laser ablation of peritoneal endometriosis continues 18 months after the surgery in about 40% of patients. A graduated increase in the number of recurrences is apparent during follow-up, most significantly in dysmenorrhea and dyspareunia. The effect of surgery on different types of pelvic pain varies. A small number of recurrences was found in pain during micturition and pain during defecation, on the other hand, less success was apparent in the treatment of dysmenorrhea.

-----

Fertil Steril. 2003 May;79(5):1086-90.
Patient satisfaction and changes in pain scores after ablative laparoscopic surgery for stage III-IV endometriosis and endometriotic cysts.
Jones KD, Sutton C.
Department of Gynaecology, Royal Surrey County Hospital, Guildford, United Kingdom. kjones@rschguilford.freeserve.co.uk

OBJECTIVE: To document the changes in pain scores 3-12 months following ablative laparoscopic surgery. Secondary outcome measures included patient satisfaction scores. DESIGN: A prospective, cohort study. SETTING: A tertiary referral center for the treatment of endometriosis. PATIENT(S): Seventy-three consecutive women with stage III-IV endometriosis and an endometrioma >2 cm. INTERVENTION(S): A laparoscopy was performed. The extraovarian endometriosis was ablated with a CO(2) laser, and the endometrioma capsule was fenestrated then ablated with the potassium-titanic-phosphate (KTP) laser or the Bicap bipolar diathermy. MAIN OUTCOME MEASURE(S): Pre- and postoperative visual analogue scores for pelvic pain were completed. Patient satisfaction was scored from 1 to 10, with a score of 10 being "most satisfied." RESULT(S): A total of 73 women with stage III-IV endometriosis and 96 cysts (23 cysts were bilateral). The mean revised American Fertility Society (AFS) score was 65.5 (range 22-128). At 12 months, the mean temporal decrease in the pain score for dyspareunia was 2.14 +/- 0.41; for dysmenorrhea, 1.52 +/- 0.38; and for chronic nonmenstrual pain, 2.37 +/- 0.43. Sixty-four (87.7%) patients were satisfied or very satisfied with the treatment. No surgical complications occurred. CONCLUSION(S): Laparoscopic ablative surgery for endometriomas in the presence of stage III-IV endometriosis is an effective treatment for relieving pelvic pain.

-----

J Chin Med Assoc. 2003 Feb;66(2):113-9.
Wound endometriosis: risk factor evaluation and treatment.
Wang PH, Juang CM, Chao HT, Yu KJ, Yuan CC, Ng HT.
Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC. phwang@vghtpe.gov.tw

BACKGROUND: Wound endometriosis is still a rare phenomenon. In this study, we tried to identify its risk factors and presented our experience in managing such disease. METHODS: We studied twenty-three women with pathologically confirmed wound endometriosis after surgery between January 1990 and June 1999 retrospectively. RESULTS: Patients were classified to three groups according to the types of operations including obstetric surgery (n = 6186), gynecologic surgery (n = 3231) and laparoscopic procedures (n = 2184), which made a significant difference in the occurrence rate of endometriosis (p = 0.04): 2.7 per 1000 obstetric surgeries, 1.5 per 1000 cases of gynecologic surgeries, and 0.5 per 1000 laparoscopic procedures. Obstetric surgery showed the relative risk of occurrence of wound endometriosis 7.71 (95%: 1.03-57.92) compared with laparoscopic procedures. The median time for occurrence of wound endometriosis in patients with normal preoperative CA-125 (< 15 mIU/ml), 760 days, was significantly longer than that in patients with abnormal preoperative CA-125 (> 15 mIU/ml) of 496 days (p = 0.03). Preoperative CA-125 level, patient's age, preoperative extent of endometriosis, or operative time made no significant contributions to the occurrence of wound endometriosis. Combination therapy of surgical excision and postoperative adjuvant therapy of GnRH-agonist or Danazol showed the better prognosis because it could decrease the recurrence of wound endometriosis (42.9% versus 11%, p = 0.01). CONCLUSION: Obstetric surgery may be an important risk factor in contributing to wound endometriosis, and the aggressive behavior of endometriosis itself might also be a possible risk factor because it shortens the time of occurrence of wound endometriosis after surgery. Therapy might be dependent on individuals. Surgical excision with postoperative adjuvant therapy of either GnRH-agonist or Danazol might be valid, although its effectiveness needed proven in the future.

-----

Obstet Gynecol Clin North Am. 2003 Mar;30(1):151-62.
Surgical management of endometriosis-associated pain.
Martin DC, O'Conner DT.
University of Tennessee, Department of Obstetrics and Gynecology, 6215 Humphreys, Suite 400, Memphis, TN 38120, USA. dnmartin46@aol.com

General surgical guidelines are reasonable, but treatment frequently must be individualized. Laparoscopic coagulation can be used for many cases of superficial endometriosis. Resection seems to be associated with an increased resolution of endometriosis. Resection increases the difficulty of the procedure, the time of the operation, and the cost, however. When endometriosis is found coincidentally, it may need no treatment because many women have endometriosis as a self-limited disease. Distinguishing patients who need no treatment from patients who need intermediate or extensive treatment can be difficult. Care is needed to attempt to ensure that patients are neither overtreated nor undertreated.

-----

Obstet Gynecol Clin North Am. 2003 Mar;30(1):133-50.
Medical management of endometriosis-associated pain.
Mahutte NG, Arici A.
Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, CT 06520, USA. neal.mahutte@yale.edu

In the coming years, basic science research into the mechanisms of endometriosis development and persistence almost certainly will open new avenues for treatment. A wide armamentarium of medical therapies already exists, however. The efficacy of most of these methods in reducing endometriosis-associated pain is well established. The choice of which to use depends largely on patient preference after an appropriate discussion of risks, side effects, and cost. Typically, oral contraceptives and NSAIDs are first-line therapy because of their low cost and mild side effects (Box 6). Because of its greater potential for suppressing endometrial development, consideration should be given to prescribing a low-dose monophasic oral contraceptive continuously. If adequate relief is not obtained or if side effects prove intolerable, consideration should be given to the use of progestins (oral, intramuscular, or IUD) or a GnRH agonist with immediate add-back therapy. Progestins are less expensive, but GnRH agonists with add-back may be better tolerated. If none of these medications proves beneficial or if side effects are too pronounced, then repeat surgery is warranted. The surgery may have analgesic value and serves to reconfirm the diagnosis. Finally, if endometriosis is identified at the time of surgery, then consideration should be given to prescribing medical therapy postoperatively.

-----

Acta Obstet Gynecol Scand. 2003 Feb;82(2):167-72.
Subdermal progestin implant (Nestorone) in the treatment of endometriosis: clinical response to
various doses.
Ylanen K, Laatikainen T, Lahteenmaki P, Moo-Young AJ.
Helsinki City Maternity Hospital, University of Helsinki, Helsinki, Finland.

OBJECTIVE: To evaluate the efficacy of three different doses of Nestorone progestin administered by implants for relief of pain, as well as bleeding patterns and symptoms in women with endometriosis. DESIGN: An open clinical study without a control group. PATIENTS: Twenty-one women in whom endometriosis was diagnosed and treated at laparoscopy or at laparotomy. INTERVENTIONS: The patients were randomly allocated to one of three groups receiving a daily dose of either 150 micro g, 200 micro g or 400 micro g Nestorone for two to four implants inserted subcutaneously for 7 months. After removal of the implants the follow-up period was 6 months. Six patients in the 150 micro g group, seven in the 200 micro g group and five in the 400 micro g group completed the study. MEASUREMENTS: Records of bleeding and registered side-effects and endometriosis-related symptoms were kept by the patients. Ovarian status was evaluated by vaginal ultrasonography. Serum concentrations of Nestorone and of lipids were measured. RESULTS: Pelvic pain decreased significantly in response to the treatment in all groups but returned to pretreatment levels during the post-treatment period. Bleeding and spotting was the most common side-effect followed by hypoestrogenic and psychic symptoms, with no significant difference among the groups. No significant changes in the serum levels of total, HDL or LDL cholesterol were found. One patient during the treatment period and four patients during the follow ups underwent surgical procedures. CONCLUSION: All three doses of Nestorone effectively alleviated endometriosis-related pain. While the Nestorone implant provides an interesting option for the treatment of endometriosis-related pain, its role needs to be assessed in comparative trials.

-----

Int J Fertil Womens Med. 2003 Jan-Feb;48(1):32-6.
Can we decrease breakthrough bleeding in patients with endometriosis on norethindrone acetate?
Muneyyirci-Delale O, Jalou S, Rahman M, Nacharaju V.
SUNY Downstate Medical Center, Brooklyn, New York 11203, USA.

OBJECTIVE: To compare the breakthrough bleeding in endometriosis patients treated with Lupron-Depot alone, norethindrone acetate following Lupron-Depot, and norethindrone acetate alone. PATIENTS AND METHODS: 71 women with symptomatic surgically diagnosed endometriosis were retrospectively evaluated for this study. 28 women were treated with 6 doses of 3.75 mg Lupron-Depot every 4 weeks (Group I). 15 women were treated first with Lupron-Depot 3.75 mg every 4 weeks for 3 to 6 doses, followed by 5 mg norethindrone acetate (Group II). 28 patients were treated for 6 months with 5 mg per day norethindrone acetate alone (Group III). Breakthrough bleeding during treatment was scored mild (some spotting), moderate (lighter than patient's normal menstruation), or severe (as much as patient's normal menstruation or heavier). Multiple comparisons were done by ANOVA (SPSS) among three groups. The age of patients was not significantly different between groups 134.9-36.8 years). BMI of the three groups was significantly different 126.6 +/- 5.8, 27.4 +/- 6.4, 23.6 +/- 4.5, respectively). RESULTS: Breakthrough bleeding was reported by 14% of Group I, 20% of Group II, and 68% of Group III. CONCLUSION: Endometriosis patients who were treated with norethindrone acetate following Lupron-Depot had significantly less breakthrough bleeding than those given norethindrone acetate alone, and the incidence was comparable to Lupron-Depot alone.

-----

Am J Obstet Gynecol. 2003 Mar;188(3):606-10.
Coagulation or excision of ovarian endometriomas?
Vercellini P, Chapron C, De Giorgi O, Consonni D, Frontino G, Crosignani PG.
First Department of Obstetrics and Gynecology, University of Milano, Italy. paolo.vercellini@unimi.it

A systematic review was undertaken to determine whether coagulation or laser vaporization of endometriomas is associated with an increase in the risk of cyst recurrence compared with excision of the pseudocapsule. In the four comparative trials identified, endometrioma recurrence was reported in 39 of 212 (18.4%) women treated with coagulation or laser vaporization compared with 19 of 295 (6.4%) in those who underwent cystectomy. The odds ratios of endometrioma recurrence ranged from 1.41 to 9.38 with 95% CIs including unity in two studies. The common odds ratio was 3.09 (95% CI 1.78-5.36). Coagulation or laser vaporization of endometriomas without excision of the pseudocapsule seems to be associated with a significant increase in risk of cyst recurrence.

-----

AORN J. 2003 Feb;77(2):298, 301-9, 312-3; quiz 314-6.
Endometriosis—a missed malady.
Taylor MM.

Endometriosis is a disease that affects approximately 5.5 million girls and women in their reproductive years in the United States and Canada. During the menstrual cycle, the endometrial lining of the uterus thickens in preparation to receive a fertilized egg. If fertilization does not occur, this lining sloughs off during menstruation. Endometrial tissue can migrate out of the fallopian tubes and grow outside of the uterus as endometrial implants. This can result in severe pain. Endometriosis is very difficult to detect because most women become accustomed to painful menstrual cycles at an early age. The disease often will go undiagnosed because even with extensive endometriosis it is possible to have minimal symptoms or none at all. Physicians have few diagnostic tools to detect the scars and growths of endometriosis. The only way to confirm the diagnosis and stage of endometriosis is by laparoscopy. Treatment options include hormone therapy and surgery. In the past, the most successful treatment was open laparotomy with excision of the endometrial implants. This article discusses the use of the ultrasonic scalpel to resect endometrial implants through the laparoscope. The patient's perioperative course also is discussed.

-----

Med Hypotheses. 2003 Jan;60(1):84-8.
Endometriosis is sustained by tumour necrosis factor-alpha.
Bullimore DW.
Barnsley District General Hospital Trust, Barnsley, UK. dwwbullimore@compuserve.com

Endometriosis is a common gynaecological disorder causing pain, infertility, and emotional distress. Evidence presented here suggests that abnormal production of tumour necrosis factor-alpha (TNF-alpha) is required for the establishment and maintenance of endometriosis and also is responsible for the associated infertility through its effect on sperm motility and function and oocyte development. Infliximab, which blocks TNF-alpha function, could be used in the treatment of endometriosis to reverse the above effects.

-----

Curr Opin Obstet Gynecol. 2003 Aug;15(4):321-6.
Ovarian endometriosis: from pathogenesis to surgical treatment.
Busacca M, Vignali M.

PURPOSE OF REVIEW This review analyzes the literature on ovarian endometrioma, examining the controversies on pathogenesis, malignant transformation and surgical therapy.RECENT FINDINGS Recent literature reflects the necessity of clearly defining the ethiologic and pathologic factors that determine the origin of ovarian endometriosis and explain the increase in the condition with the prospect of developing effective prevention therapy. The possibility that ovarian endometriomas undergo malignant transformation is widely reported in the literature. Recent studies underline the importance of detecting histological differences in endometriosis (hyperplasia and atypia) and several studies of molecular biology support the theory of genetic alterations interfering with malignant transformation of ovarian endometriosis.SUMMARY The surgical approach must take into account all this information and, when the therapy is conservative, complete excision of the disease must be laparoscopically performed without affecting the healthy ovarian tissue.

-----

Gynecol Obstet Fertil. 2003 Apr;31(4):337-42.
[Laser vaporization of ovarian endometriomas: the impact on the response to gonadotrophin stimulation]
[Article in French]
Wyns C, Donnez J.
Service de gynecologie, cliniques universitaires Saint-Luc, Universite catholique de Louvain, 10, avenue Hippocrate, 1200, Bruxelles, Belgique.

OBJECTIVE: To evaluate the ovarian response to stimulation for IVF in endometriosis patients who have previously undergone laparoscopic treatment of peritoneal and/or ovarian endometriosis (CO2 laser vaporization). PATIENTS AND METHODS: Retrospective study of 455 patients undergoing IVF. The study group, made up of 127 endometriosis patients, was divided into 2 subgroups: Ia: 42 women with peritoneal endometriosis, treated by laparoscopy, who underwent 71 IVF cycles; Ib: 85 women with ovarian endometriomas, treated by vaporization of the internal wall, who underwent 187 IVF cycles. The control group, consisting of 328 women, was also divided into 2 subgroups: IIa: 193 women suffering from tubal infertility who underwent 422 IVF cycles; IIb: 135 women with idiopathic infertility who underwent 275 IVF cycles. RESULTS: The ovarian stimulation parameters (number of gonadotrophin ampoules, number of follicles and mature oocytes, maximum estradiol concentrations) were not significantly different in the various subgroups. The number of embryos obtained and transferred per cycle, the fertilization rates (group Ia: 61.81%; Ib: 60.90%; IIa: 62.48%; IIb: 57.99%), the implantation rates (group Ia: 17.72%; Ib: 15%; IIa: 13.94%; IIb: 18.05%) and the clinical pregnancy rates (group Ia: 32.39%; Ib: 37.40%; IIa: 27.49%; IIb: 30.18%) were not statistically different in the studied subgroups. DISCUSSION AND CONCLUSION: The theoretical risk of loss of ovarian cortex when treating endometriotic cysts can be eliminated by the technique of vaporization of the internal wall of the endometrioma.IVF outcomes are similar in patients treated for endometriosis and those presenting with unexplained or tubal infertility.

-----

J Urol. 2003 Jul;170(1):20-5.
Ureteral endometriosis.
Yohannes P.
Division of Urology, Department of Surgery, Creighton University, Omaha, NE, USA.

PURPOSE: This review discusses the pathophysiology, presentation, and different minimally invasive medical and surgical treatment options for ureteral endometriosis. MATERIALS AND METHODS: A comprehensive literature review of reports on the diagnosis and management of ureteral endometriosis was performed using MEDLINE. RESULTS: Ureteral endometriosis is a rare disease. Most cases present with silent obstruction, as opposed to cyclical hematuria. The diagnosis of ureteral endometriosis requires a high index of suspicion. A variety of diagnostic tests can help identify the extent of disease and the degree of renal function on the side of ureteral involvement. CONCLUSIONS: Ureteral endometriosis can be treated with hormones or surgical intervention. While surgery is reserved for hormone refractory cases and obstruction associated with extensive scarring, the majority of cases can be managed with hormones only. A combination of hormones and surgery is also effective. Surveillance for obstructive uropathy with periodic noninvasive monitoring of kidney function is currently recommended for all patients with endometriosis.

-----

Eur J Gynaecol Oncol. 2002;23(6):523-6.
Depot leuprorelin acetate versus danazol in the treatment of infertile women with symptomatic endometriosis.
Rotondi M, Labriola D, Rotondi M, Ammaturo FP, Amato G, Carella C, Izzo A, Panariello S.
Institute of Obstetrics and Gynecology, II University of Naples, Italy.

PURPOSE OF INVESTIGATION: Endometriosis is a common finding in women with infertility, but the mechanism by which it renders a woman infertile remains unclear. The medical treatment of pelvic endometriosis includes hormonal therapy that directly attacks endometriosis lesions or indirectly by inhibiting endometrial proliferation through estrogenic deprivation. The aim of this study was to compare the efficacy and safety of leuprorelin acetate depot and danazol for endometriosis in infertile women. METHODS: This randomized trial involved 81 women 19-41 years old with regular menses and known pelvic endometriosis who were recruited from the Fertility Center of the Second University of Naples between 1992 and 1999. Fifty-four women were given 3.75 mg of leuprolide acetate depot every 28 days for 24 weeks and the remaining 27 took 200 mg of danazol three times daily for 24 weeks. Efficacy assessments were based on pre-admission and end-of-treatment laparoscopic scores and subjective symptoms scores at 4-week intervals during and after treatment. Safety was evaluated by adverse events and clinical laboratory tests. RESULTS: In each group, endometriosis growth and symptoms significantly improved during treatment (p < 0.001). Significantly fewer patients randomized to leuprorelin acetate (5.5%) withdrew during treatment compared with 18.5% randomized to danazol (p < 0.05). After treatment symptoms returned in each group, but severity was less than at admission at all time points (p < 0.02). Hypoestrogenic side-effects were more common in those receiving leuprorelin, particularly hot flushes, but anabolic/androgenic side-effects of weight gain and acne were more common in those receiving danazol. CONCLUSION: Both leuprorelin acetate depot and danazol are effective in the treatment of endometriosis in infertile patients. The hypoestrogenic side-effects of leuprorelin may be better tolerated than the androgenic, anabolic effects of danazol.

-----

J Am Coll Surg. 2002 Dec;195(6):754-8.
Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement.
Duepree HJ, Senagore AJ, Delaney CP, Marcello PW, Brady KM, Falcone T.
Department of Colorectal Surgery, and The Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.

BACKGROUND: Adequate treatment of severe deep pelvic endometriosis requires complete excision of all implants, but formal bowel resection is not generally recommended. The purpose of this study was to describe our experience with planned complete laparoscopic management of deep pelvic endometriosis with bowel involvement. STUDY DESIGN: All patients presenting to the Department of Obstetrics and Gynecology and the Department of Colorectal Surgery at our institution with stage IV endometriosis and bowel involvement from February 1998 to December 2001 were identified from a prospective database and were retrospectively analyzed. Data analysis included age, previous history of endometriosis, previous pregnancies, operative procedure, body mass index, operating room time, intra- and postoperative complications, length of stay, 30-day readmission, and pain relief. Laparoscopic excision of all visible disease was planned. RESULTS: The series consisted of 51 patients with median age of 34 years (range, 32 to 39 years), with history of earlier abdominal operation in 66.7%. Preoperative symptoms were present as dysmenorrhea (85.3%), dyspareunia (55.9%), rectal pain (41.2%), constipation (44.1%), rectal bleeding (14.7%), bloating (29.4%), and tenesmus (8.8%). Management of the bowel disease included superficial excision of serosal endometriosis implants (n = 26), bowel resection (n = 18), and disc excision (n = 5). Five patients required management of disease other than rectosigmoid involvement. Median operating room time was 187 minutes (range, 145 to 277 minutes), and the median length of stay was 2 days (range, 1 to 4 days). Thirty-three percent of excisions were outpatient procedures. Postoperative complications occurred in 10.3%: four cases (7.8%) were converted to formal laparotomy, and three patients (7.7%) were readmitted within 30 days. Only 7 of 47 patients with a uterus (14.9%) required abdominal hysterectomy or bilateral salpingo-oophorectomy. Postoperatively, 87% of patients reported a clinically significant improvement of their symptoms. CONCLUSIONS: Though technically demanding, complete radical laparoscopic excision of endometriotic implants can be accomplished with preservation of the reproductive organs and appropriate use of bowel resection in the majority of patients. The surgeon or gynecologist who plans to perform laparoscopic excision of deep pelvic endometriosis should have the ability or access to expertise for laparoscopic partial or segmental bowel resection or plan to convert to laparotomy when faced with this disease location.

-----

Urol Clin North Am. 2002 Aug;29(3):625-35.
Endometriosis of the urinary tract.
Comiter CV.
University of Arizona College of Medicine, P.O. Box 245077, 1501 N. Campbell Avenue, Tucson, AZ 85724, USA. ccomiter@u.arizona.edu

Genitourinary endometriosis is a rare manifestation of a common disease. Ectopic endometrial tissue may extrinsically involve or intrinsically invade the bladder or ureter, and, less commonly, the urethra or kidney. Bladder involvement usually presents with irritative symptoms, whereas ureteral disease may present with asymptomatic renal failure. Therefore, a high index of suspicion is necessary, and genitourinary endometriosis should be considered in all symptomatic women with a history of cesarean delivery of other gynecologic surgery. In women beyond reproductive age, definitive surgical treatment is preferred, with removal of the ectopic tissue, relief of obstruction, and castration with or without hysterectomy. In those who desire future fertility, conservative surgery and/or hormonal therapy is often recommended.

-----

Reprod Biomed Online. 2002 Jul-Aug;5(1):12-6.
Use of GnRH antagonists in the treatment of endometriosis.
Kupker W, Felberbaum RE, Krapp M, Schill T, Malik E, Diedrich K.
Department of Obstetrics and Gynaecology, Medical University Lubeck, Ratzeburger Allee 160, 23538 Lubeck, Germany. wkupker@hotmail.com

Endometriosis is an oestrogen-dependent disease that is treatable by oestrogen withdrawal, a therapy that has been effectively provided by the use of a gonadotrophin-releasing hormone (GnRH) agonist. Complete oestrogen withdrawal results in unacceptable side-effects, in particular in accelerated bone density loss. This problem has been effectively overcome with 'add-back therapy' using low-dose oestrogens and progestins in combination with a GnRH agonist to limit these side-effects, while still allowing regression of endometriotic lesions. The aim of this study was to determine the feasibility of using a subcutaneous injection of GnRH antagonist in the treatment of endometriosis. All patients (15/15; 100%) reported a symptom-free period during GnRH antagonist treatment, including mood changes, hot flushes, loss of libido, vaginal dryness and other symptoms. Serum oestradiol oscillated around a mean concentration of 50 pg/ml during therapy. Diagnostic laparoscopy before GnRH antagonist administration showed a mean stage III of disease. Regression occurred in 60% of cases (9/15) and the degree of endometriosis declined to stage II. Sequential administration of the GnRH antagonist cetrorelix (Cetrotide) in a 3 mg dosage once weekly over 8 weeks creates a new opportunity for medical treatment of symptomatic endometriosis. Preserving basic oestrogen production during the course of treatment apparently does not influence regression of disease, and has no major side-effects.

-----

Minerva Pediatr. 2002 Dec;54(6):525-38.
[Dysmenorrhea, endometriosis and premenstrual syndrome]
[Article in Italian]
Tonini G.
Centro di Endocrinologia Pediatrica-Auxologia, Clinica Pediatrica, IRCCS Burlo Garofolo, Trieste, Italy.

Dysmenorrhea is the most frequent gynaecological problem in adolescent girls (the prevalence is 80-90%). Genetic influence, style of life (diet and physical activity) social, economical and cultural factors can affect symptoms. Prostaglandins and leucotrienes produced by endometrium, abnormal uterine smooth muscle contractility and modifications of the local blood flow are responsible for abdominal pain. Frequently daily activities are negatively affected (missing time at school) dysmenorrhoea can be primary or secondary to anatomical anomalies of internal genitalia or presence of synechie (post surgery or inflammatory pelvic diseases). Therapy may consist of traditional medicine (relaxing techniques such as yoga, agopuncture, mild analgesic drugs or more effective FANS). In case of therapeutical failure, contraceptive and/or GnRH agonists can represent the last choice. Endometriosis is less frequent, etiopatogenesis is not completely understood, but the anatomical lesions consist of an oestrogen-dependent neo-angiogenesis. Oestrogen inhibitors, oral contraceptives or GnRH agonists may be useful in treating this pathology. In case of drug failure surgery is suggested. For the effective diagnosis laparoscopy and biopsy are absolutely necessary. Premenstrual syndrome is cyclical, extremely complex, unusual in adolescent girls, sometimes associated to pre-existent psychic disorders. It can be treated with symptomatic drugs or, more recently, using drugs that alter the levels of serotonin, but their use in the adolescent patient is not yet recommended.

-----

Akush Ginekol (Sofiia). 2002;41(3):36-42.
[Gonadotropin releasing hormone (GnRH) antagonists--a new provocation in gynecology]
[Article in Bulgarian]
Vladimirov Ia.

Within the last years, there have been reports on the use of GnRH antagonists, as opposed to agonists, in the treatment of the patients with infertility, uterine fibroids, endometriosis and precocious puberty. The advantage of the antagonists is that they will directly inhibit the action of GnRH on the pituitary, inducing an immediate fall in secretion of luteinizing hormone(LH) and follicle-stimulating hormone(FSH). GnRH antagonists has been shown to be useful also for other clinical indication, such as ovarian, endometrial, prostate and breast cancers.

-----

Surg Endosc. 2002 Nov;16(11):1513-7. Epub 2002 Jul 29.
Laser laparoscopy for endometriosis and endometriotic cysts.
Sutton CJ, Jones KD.
Guildford Nuffield Hospital, Stirling Road, Guildford, United Kingdom.

BACKGROUND: Endometriosis is a common and debilitating condition involving women during their reproductive years. It is characterized by the occurrence of endometrial glands and stroma outside the uterine cavity. Presenting symptoms include chronic nonmenstrual pelvic pain, dysmenorrhea, dyspareunia, and subfertility. The condition is diagnosed at laparoscopy, and operative laparoscopic surgery for endometriosis is also possible. METHODS: This article critically evaluates the evidence for the laparoscopic management of endometriosis and endometriotic cysts. It focuses on laser laparoscopy and reviews the contribution made by the Minimal Access Therapy Training Unit, Guildford, UK, to the treatment of this condition. RESULTS: Few randomized controlled trials have been undertaken to evaluate the surgical management of endometriosis. The studies that have been done show that laparoscopic surgery, including laser laparoscopy, is effective in the management of painful symptoms and subfertility and preventing cyst recurrence. Several of the landmark studies in this area have been carried out in Guildford. CONCLUSION: Laparoscopic surgery is the treatment of choice for patients with endometriosis and endometriotic cysts.

------

Orv Hetil. 2002 Jun 16;143(24):1475-8.
[Comparative study of the efficiency of gonadotrope releasing hormone (GnRH) analogs for the
treatment of endometriosis]
[Article in Hungarian]
Kereszturi A, Daru J, Pal A.
Szegedi Tudomanyegyetem Altalanos Orvostudomanyi Kar, Szent-Gyorgyi Albert Orvos- es Gyogyszeresztudomanyi Centrum Szuleszeti es Nogyogyaszati Klinika, Szeged. kereszturi@obgyn.szote.u-szeged.hu

INTRODUCTION: Endometriosis is one of the most common gynaecological conditions in women of reproductive age. The aim of the authors' study was to compare the relative safety, efficacy and side effects of nafarelin and triptorelin. PATIENTS AND METHODS: They treated 133 patients for six months and followed up for at least an additional 6 months. In the diagnosis of the endometriosis they use the gold standard, the laparoscopy. RESULTS: During the 6-month therapy with analogues, there was a noticeable decline in the symptoms of the disease, there was no significant change in the efficacy and was no difference in main side effects of the two drugs. CONCLUSION: These treatments represent favourable approaches in the management of endometriosis.

-----

Arch Ital Urol Androl. 2002 Mar;74(1):1-2.
[Clinical picture and therapy of endometriosis]
[Article in Italian]
Zacche G.
Unita Operativa Complessa di Ostetricia e Ginecologia, Azienda Ospedaliera Carlo Poma, Mantova.

This paper defines endometriosis disease and summarizes its clinical and pathological features. Definitive diagnosis of endometriosis requires direct visualization of the disease. Laparoscopy is the most commonly employed method to inspect the peritoneal cavity directly. We list the drugs employed for the medical therapy of endometriosis and put evidence on limits and side effects of medical treatment. The surgical treatment is mainly laparoscopic for excision or coagulation of pelvic endometriosis implants but frequently the rate of recurrences or new implants is high. In this paper we stressed the urological aspect of endometriosis in particular bladder and ureteral locations and the secondary ureteral injuries resulting from surgical treatment.

-----

Ann N Y Acad Sci. 2002 Mar;955:360-72; discussion 389-93, 396-406.
The treatment of endometriosis: a review of the evidence.
Olive DL, Pritts EA.
Department of Obstetrics and Gynecology, University of Wisconsin-Madison Medical School, 53792-6188, USA. lapskyboy@aol.com

The treatment of endometriosis focuses upon amelioration of two symptoms: pain and infertility. The treatment of endometriosis-associated pain has been well studied and all major medical therapies appear to be superior to placebo. In addition, none seems to be drastically better than another. Surgical therapy also appears to be efficacious, albeit with a relatively high rate of recurrence of symptoms following conservative surgical intervention. There are no trials comparing the relative value of medical versus surgical therapy. Combination surgery/medical therapy has several high-quality trials for evaluation, but its value remains unclear. The treatment of endometriosis-associated infertility presents a different picture: medical therapy has not been shown to be of any value and may prove detrimental to fertility. Surgical treatment does improve fertility, probably for all stages of disease. Assisted reproduction also seems to be efficacious, with both controlled ovarian hyperstimulation and intrauterine insemination as well as in vitro fertilization shown to be of benefit. Finally, the combination of in vitro fertilization and either medical or surgical therapy may be beneficial with advanced endometriosis, but further study is required.

-----

Ann N Y Acad Sci. 2002 Mar;955:343-52; discussion 389-93, 396-406.
Conventional medical therapies for endometriosis.
Rice VM.
Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City 66160, USA. vmontgomery-rice@kumc.edu

Endometriosis is a common gynecologic disorder that affects approximately 14% of all women and 30% to 50% of infertile women. Since the most common symptoms of endometriosis--progressive dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility--are also symptoms of multiple disorders, a diagnosis of endometriosis can be elusive and confirmed only by visualization, that is, laparoscopy. Endometriosis is often treated surgically upon diagnosis; however, the rate of recurrence is high, suggesting that a combination of therapeutic approaches might provide better outcomes than any one option alone. The most widely utilized hormonal treatments for endometriosis are GnRH agonists and oral contraceptives; agents indicated by the Food and Drug Administration include GnRH agonists and the androgen, danazol. The majority of evidence in support of medical therapy for endometriosis is largely observational, with the exception of studies of GnRH agonists, danazol, and a few progestins. Conventional treatment approaches for the medical management of endometriosis focus on suspected endometriosis, following a diagnosis of endometriosis, following surgical treatment of endometriosis, long-term management, and retreatment. Although major advances have been made in the treatment of endometriosis in recent decades, lack of randomized clinical trials evaluating the use of agents such as oral contraceptives alone or as add-back therapy for GnRH agonists, or those that examine combined medical and surgical treatments, has hampered the ability of physicians to provide the broadest range of medical therapies for this disorder. Future trials addressing these issues are warranted.

The Endometriosis FileSM Compiled and Maintained by    The Center for Current Research, Inc. 708 Aubrey Avenue • Ardmore PA USA 19003 Phone: 610-649-3165 Email: customerservice@lifestages.com Website: www.lifestages.com

©Copyright 1992-date by The Center for Current Research. The Endometriosis File is a proprietary compilation of the Center for Current Research. The information in the File is solely for your use, and the use of your family, friends, and doctors. The information is the property of the individual researchers and institutions that produced it. It is an infringement of copyright law to attempt to "resell" the information as it is presented here.