Estrógeno potenciado en el tratamiento homeopático del dolor pélvico asociado a endometriosis: un estudio aleatorizado, doble ciego, controlado con placebo, de 24 semanas / Potentiated estrogen in the homeopathic treatment of pelvic pain associated with endometriosis: a 24-week randomized, double-blind, placebo-controlled study

Evaluar la eficacia y seguridad del estrógeno potenciado en comparación con el placebo en el tratamiento homeopático del dolor pélvico asociado a endometriosis (EAPP, por sus siglas en inglés). Diseño del estudio: El presente fue un estudio clínico aleatorizado, doble ciego, controlado con placebo, de 24 semanas, el cual incluyó a 50 mujeres de entre 18 y 45 años de edad con diagnóstico de endometriosis infiltrante profunda con base en ultrasonido transvaginal o imágenes de resonancia magnética después de preparación intestinal, así como puntaje ≥ 5 en una escala visual analógica (VAS: rango de 0 a 10 puntos) para el dolor pélvico asociado con la endometriosis. Se administró estrógeno potenciado (12cH, 18cH y 24cH) o placebo dos veces al día por vía oral. La medida principal de resultado fue el cambio en la severidad de los puntajes parcial y global de EAPP (VAS) de la línea basal a la semana 24, determinada como la diferencia en el puntaje medio de cinco modalidades de dolor pélvico crónico (dismenorrea, dispareunia profunda, dolor pélvico no cíclico, dolor intestinal cíclico y/o dolor urinario cíclico). Las medidas secundarias de resultado fueron la diferencia media de puntaje para la calidad de vida evaluada con el Cuestionario de Salud SF-36, los síntomas de depresión en el Inventario de la Depresión de Beck (BDI) y los síntomas de ansiedad en el Inventario de Ansiedad de Beck (BAI). Resultados: El puntaje global de EAPP (VAS: rango de 0 a 50 puntos) se redujo en 12.82 (p < 0.001) en el grupo tratado con estrógeno potenciado de la línea basal a la semana 24. El grupo que utilizó estrógeno potenciado también presentó una reducción en el puntaje parcial (VAS: rango de 0 a 10 puntos) en tres modalidades de EAPP: dismenorrea (3.28; p < 0.001), dolor pélvico no cíclico (2.71; p = 0.009) y dolor intestinal cíclico (3.40; p < 0.001). El grupo de placebo no mostró cambio significativo alguno en los puntajes global o parcial de EAPP. Además, el grupo de estrógeno potenciado mostró un mejoramiento significativo en tres de ocho ámbitos de SF-36 (dolor de cuerpo, vitalidad y salud mental) y síntomas de depresión (BDI). El grupo de placebo no mostró un mejoramiento significativo a este respecto. Estos resultados demuestran la superioridad del estrógeno potenciado sobre el placebo. Se asociaron pocos eventos adversos con el estrógeno potenciado. Conclusiones: El estrógeno potenciado (12cH, 18cH y 24cH) en dosis de 3 gotas dos veces al día durante 24 semanas fue significativamente más efectivo que el placebo para reducir el dolor pélvico asociado con la endometriosis. Registro del estudio clínico: ClinicalTrials.gov Identificador: https://clinicaltrials.gov/show/NCT02427386.

To evaluate the efficacy and safety of potentized estrogen compared to placebo in homeopathic treatment of endometriosis-associated pelvic pain (EAPP). Study design: The present was a 24-week, randomized, doubleblind, placebocontrolled trial that included 50 women aged 18-45 years old with diagnosis of deeply infiltrating endometriosis based on magnetic resonance imaging or transvaginal ultrasound after bowel preparation, and score ≥ 5 on a visual analogue scale (VAS: range 0 to 10 points) for endometriosis-associated pelvic pain. Potentized estrogen (12cH, 18cH and 24cH) or placebo was administered twice daily per oral route. The primary outcome measure was change in the severity of EAPP global and partial scores (VAS) from baseline to week 24, determined as the difference in the mean score of five modalities of chronic pelvic pain (dysmenorrhea, deep dyspareunia, non-cyclic pelvic pain, cyclic bowel pain and/or cyclic urinary pain). The secondary outcome measures were mean score difference for quality of life assessed with SF-36 Health Survey Questionnaire, depression symptoms on Beck Depression Inventory (BDI), and anxiety symptoms on Beck Anxiety Inventory (BAI). Results: The EAPP global score (VAS: range 0 to 50 points) decreased by 12.82 (p < 0.001) in the group treated with potentized estrogen from baseline to week 24. Group that used potentized estrogen also exhibited partial score (VAS: range 0 to 10 points) reduction in three EAPP modalities: dysmenorrhea (3.28; p < 0.001), non-cyclic pelvic pain (2.71; p = 0.009), and cyclic bowel pain (3.40; p < 0.001). Placebo group did not show any significant changes in EAPP global or partial scores. In addition, the potentized estrogen group showed significant improvement in three of eight SF-36 domains (bodily pain, vitality and mental health) and depression symptoms (BDI). Placebo group showed no significant improvement in this regard. These results demonstrate superiority of potentized estrogen over placebo. Few adverse events were associated with potentized estrogen. Conclusions: Potentized estrogen (12cH, 18cH and 24cH) at a dose of 3 drops twice daily for 24 weeks was significantly more effective than placebo for reducing endometriosis-associated pelvic pain.

Investigation of familial tendency of endometriosis / 中华妇产科杂志

Objective: To investigate the familial heritability of endometriosis and to compare the clinical characteristics of patients with or without a family history of endometriosis. Methods: From January 2020 to June 2022, 850 patients with endometriosis confirmed by laparotomy or laparoscopy in Peking University Third Hospital were included in this study. Clinical data were collected, family history was followed up, and the differences of clinical indicators between patients with and without family history of endometriosis were compared. Results: A total of 850 patients were enrolled, with an average age of (33.8±7.0) years old, 315 (37.1%, 315/850) patients in stage Ⅲ and 496 (58.4%, 496/850) patients in stage Ⅳ. There were 100 patients with family history of endometriosis, accounting for 11.8% (100/850). Most of the 113 relatives involved were mothers, daughters and sisters (76.1%, 86/113), 81.5% (22/27) of the second and third degree relatives were maternal relatives. The median ages of patients with and without family history of endometriosis were 30 and 33 years old respectively at the time of diagnosis. The unmarried rate of patients with family history was higher [42.0% (42/100) vs 26.3% (197/750)]. The percentage of dysmenorrhea patients with family history was higher [89.0% (89/100) vs 55.5% (416/750)]. The medians of dysmenorrhea score in patients with and without family history were 6 and 2, and the median durations of dysmenorrhea were 10 and 1 years. There were significant differences in age, marital status, percentage of dysmenorrhea, dysmenorrhea score and duration (all P<0.001). The median levels of serum cancer antigen (CA) 125 in patients with family history and patients without family history at the time of diagnosis were 57.5 and 46.9 kU/L respectively, with a statistically significant difference (P<0.05). However, there were no significant differences between the two groups in nationality, bady mass index, menarche age, menstrual cycle, menstrual period, menstrual volume, serum CA19-9 level, cyst location and size, stage, history of adverse pregnancy and childbirth, infertility, adenomyosis and deep infiltrating endometriosis (all P>0.05). By comparing the specific conditions of dysmenorrhea patients with and without family history of endometriosis, there were no significant differences between the two groups in terms of the age of onset of dysmenorrhea, duration of dysmenorrhea, primary and secondary dysmenorrhea, and progressive aggravation of dysmenorrhea (all P>0.05). The difference in the degree of dysmenorrhea in dysmenorrhea patients with family history of endometriosis was significant (P<0.001). Conclusions: The incidence of endometriosis has a familial tendency, and most of the involved relatives are the first degree relatives. Compared with patients without family history of endometriosis, endometriosis patients with family history are diagnosed at an earlier age, with higher percentage of dysmenorrhea, had more severe dysmenorrhea and higher serum CA125 level.

Intususcepción apendicular por foco endometriósico: un caso clínico / Appendiceal intussusception caused by endometriosis: a clinical case

Resumen Objetivo: Reportar el caso de una paciente con intususcepción apendicular (IA), condición infrecuente, secundario a foco de endometriosis, patología que en los últimos años ha presentado un aumento en su incidencia. Material y Método: Historia clínica, imágenes preoperatorias e intraoperatorias obtenidas de la ficha clínica. Resultados: Mujer de 35 años con dolor abdominal crónico de 4 meses de evolución. Se realiza estudio colonoscópico evidenciando lesión de 15 x 8 mm en ostium apendicular intususceptada al lumen cecal, y enteroclisis por tomografía axial computarizada (TC) que confirma IA. Se realiza una resección ileocecal laparoscópica demostrando la invaginación del apéndice con biopsia que muestra un foco de endometrioma. Discusión: La IA es una condición infrecuente con una incidencia cercana al 0,01% en la población general. Las patologías benignas son la principal causa (77%), siendo la endometriosis la causa más frecuente. Conclusión: La IA por endometriosis es anecdótica, con sintomatología poco específica. Los estudios disponibles pueden orientar adecuadamente la presencia de IA, sin embargo, en algunas ocasiones puede confundirse con patologías neoplásicas, donde cobra importancia la cirugía para dilucidar la etiología.

Objective: To report the case of a patient with appendicular intussusception (AI), an infrequent condition secondary to a focus of endometriosis, a pathology that has increased incidence in recent years. Material and Method: Clinical case, history and images obtained from the clinical file and intraoperative records with the consent of the patient. Results: A 35-year-old woman with abdominal pain. Colonoscopy study showing a 15 × 8 mm lesion in the appendicular ostium intussuscepted to the cecal lumen, and a computerized tomography (CT) enteroclysis confirming AI. A laparoscopic ileocecal resection is performed, demonstrating invagination of the appendix secondary to an endometrioma focus. Discussion: AI is a rare condition, with an incidence close to 0.01% in the general population. Benign pathologies are the main cause (77%), endometriosis being the most frequent cause. Conclusion: AI due to endometriosis is anecdotal, with unspecific symptoms. The available studies can adequately guide the presence of AI, however, on some occasions it can be confused with neoplastic pathologies, where surgery is important to elucidate the etiology.

CO2 laser moxibustion for endometriosis related pelvic pain of cold coagulation and blood stasis: a randomized controlled trial / 中国针灸

OBJECTIVE@#To observe the clinical therapeutic effect of CO2 laser moxibustion on endometriosis related pelvic pain of cold coagulation and blood stasis.@*METHODS@#A total of 76 patients with endometriosis related pelvic pain of cold coagulation and blood stasis were randomized into a laser moxibustion group and a sham laser moxibustion group, 38 cases in each group. In the laser moxibustion group, moxibustion was applied at bilateral Zigong (EX-CA 1) using CO2 laser moxibustion instrument. In the sham laser moxibustion group, the manipulation of moxibustion was same as the laser moxibustion group, without laser output. The treatment was given once every other day, 30 min each time, 3 times a week for 4 weeks in both groups. Before and after treatment and follow-up of 3 months after treatment, the scores of Gracely box scale (GBS) and visual analogue scale (VAS) were observed, the usage of non-steroidal anti-inflammatory drug for the duration of the treatment and the average days of taking drugs were recorded in both groups.@*RESULTS@#Compared before treatment, the GBS and VAS scores were decreased after treatment and during follow-up in the laser moxibustion group (P<0.05), while those in the sham moxibustion group had no significant differences (P>0.05). Compared with the sham moxibustion group, the GBS and VAS scores were decreased after treatment and during follow-up (P<0.05), the cases and average days of taking drugs were less in the laser moxibustion group (P<0.05).@*CONCLUSION@#CO2 laser moxibustion can improve the pain symptom in patients with endometriosis related pelvic pain of cold coagulation and blood stasis, and reduce the use of analgesic drugs.

Analysis of the factors contributing to endometriosis in China and UK / 南方医科大学学报

OBJECTIVE@#To explore the differences in the factors associated with endometriosis between Chinese and British patients.@*METHODS@#This case-control study was conducted in 387 patients with endometriosis and 199 non-endometriosis patients admitted to John Radcliffe Hospital (Oxford, UK) and in 101 patients with endometriosis and 50 non-endometriosis patients admitted in the First Affiliated Hospital of Guangzhou University of Chinese Medicine. The clinical data including height, weight, body mass index, marital status, employment, menstruation, fertility, and operation reasons were collected via a standardized WERF EPHect questionnaire.@*RESULTS@#Multivariate logistic regression analysis indicated that body mass index, surgery for dysmenorrhea, history of pregnancy, counts of previous surgeries for endometriosis and status of employment were all significantly associated with endometriosis in the UK (P < 0.05), while a history of dysmenorrhea was significantly correlated with endometriosis in Chinese patients (P < 0.05).@*CONCLUSION@#Dysmenorrhea may be the most important common factor associated with endometriosis in China and the UK, but the other factors contributing to endometriosis may differ between these two countries.

"A little monster inside me that comes out now and again": endometriosis and pain in Austria / "Um pequeno monstro dentro de mim que sai de vez em quando": endometriose e dor na Áustria / "Un pequeño monstruo dentro de mí que sale una y otra vez": endometriosis y dolor en Austria

Abstract: The topics of endometriosis and pain imply far-reaching problems for women's health. Using a qualitative research approach, this paper addresses the subjective experience and effects of pain, the methods for dealing with these issues, and the needs of affected women in Austria. Data were collected by problem-focused interviews conducted with ten women suffering from endometriosis, which were later transcribed and subjected to qualitative content analysis. Findings are therefore described using content-related categories. Results show that negative thoughts and feelings like fear, despair, and anger are associated with endometriosis and pain. Moreover, predominantly negative impacts and changes are found in various areas of life, such as the well-being and psyche of those affected, their attitude towards life in general, partnerships, social life, leisure time and work-life balance. In dealing with endometriosis and pain, both Western biomedicine and complementary medicine treatments are used. Support from one's inner circle of friends and exchange and interaction with others affected by the disease are seen to be invaluable. Attending physicians as well as patients themselves and their private, social, and working environment should encourage open communication about endometriosis and the related pain.

Resumo: O tema da endometriose e dor tem implicações relevantes para a saúde das mulheres. O artigo procura contextualizar a experiência subjetiva e os efeitos da dor, os métodos para lidar com essas questões e as necessidades das mulheres afetadas por essa condição na Áustria. Foi escolhida uma abordagem qualitativa para examinar esses temas. Foram realizadas entrevistas focadas em problemas com dez mulheres com história de endometriose. Após a transcrição do material, foi realizada a análise qualitativa do conteúdo. Assim, os achados são retratados com o uso de categorias relacionadas ao conteúdo. Os resultados mostram que pensamentos e sentimentos negativos como medo, desesperança e raiva estão associados com a endometriose e dor. Além disso, são encontrados impactos e mudanças predominantemente negativos em vários domínios da vida, tais como o bem-estar e o estado psicológicos das mulheres afetadas, a atitude geral em relação à vida, parcerias, vida social, tempo de lazer e equilíbrio entre trabalho e vida pessoal. Tanto a medicina ocidental quanto os tratamentos da medicina complementar são utilizados no manejo da endometriose e da dor. O apoio do círculo próximo de amigas e as trocas e interação com outras pessoas afetadas pela doença são vistos como extremamente úteis. Os médicos atendentes e as próprias pacientes e seus ambientes privados, sociais e laborais devem incentivar a comunicação aberta sobre a endometriose e a dor associada.

Resumen: La endometriosis y su dolor asociado implican problemas profundos para la salud de las mujeres. El objetivo de este trabajo es identificar la experiencia subjetiva y los efectos del dolor, los métodos para tratarlos, así como las necesidades de las mujeres afectadas en Austria. Para el examen de los temas mencionados anteriormente, se eligió un enfoque de investigación cualitativo. Las entrevistas enfocadas en los problemas se realizaron con diez mujeres que sufrían endometriosis. Tras la transcripción material de los datos, el análisis se realizó usando un análisis cualitativo de contenido. Por lo tanto, los resultados se describen usando categorías relacionadas con el contenido. Los resultados muestran que los pensamientos negativos y los sentimientos como miedo, desesperación, y enfado están conectados con la endometriosis y el dolor. Además, predominantemente se encontraron impactos negativos y cambios en varias áreas de la vida, tales como: bienestar, psique de quienes se veían afectadas, su actitud ante la vida en general, relaciones, vida social, equilibrio entre tiempo de ocio y trabajo. Para enfrentarse a la endometriosis y el dolor, se utilizan tratamientos biomédicos occidentales, así como medicina complementaria. El apoyo del círculo íntimo de los afectados, como son los amigos, así como el intercambio e interacción con otras personas afectadas por la enfermedad parecen ser muy útiles. Ir al médico, el entorno privado, social y laboral de las pacientes, así como ellas mismas, deben estar y ser animadas para una comunicación abierta sobre la endometriosis y el dolor relacionado con la misma.

Exclusión renal por endometriosis profunda ureteral: a propósito de un caso / Renal exclusion due to deep infiltrating ureteral endometriosis: a case report

INTRODUCCIÓN: La endometriosis ureteral es una afección rara que afecta al 0.01-1,7% de las mujeres con endometriosis. Hasta un 30% cursa de forma asintomática y un 11,5-14,7% pueden evolucionar con falla renal. La falta de diagnóstico de la enfermedad puede terminar en una uropatía obstructiva y falla renal irreversible. Se presenta el caso de una paciente con afectación grave de la función renal secundaria a endometriosis profunda con compromiso ureteral. CASO CLÍNICO: Mujer de 35 años con endometriosis que consultó por exacerbación de los síntomas. En su estudio destaca, en la resonancia magnética, el hallazgo de endometriosis pélvica profunda y compromiso endometriósico intrínseco del uréter distal derecho, provocando una acentuada hidroureteronefrosis. El cintigrama renal demuestra acentuado compromiso de la función renal derecha, con una función relativa del 7%. Se realizaron nefrectomía total derecha y resección de enfermedad pélvica profunda laparoscópica, sin incidentes. CONCLUSIONES: La endometriosis ureteral representa un desafío diagnóstico y terapéutico. El manejo multidisciplinario entre radiólogos, ginecólogos y urólogos, mediante el diseño de una estrategia quirúrgica individualizada, es imprescindible para definir el tratamiento óptimo de estas pacientes.

INTRODUCTION: Ureteral endometriosis is a rare entity that affects 0.01-1,7% of women with endometriosis. Up to 30% of the patients are asymptomatic and 11.5-14.7% will develop renal failure. Misdiagnosis can lead to obstructive uropathy and permanent renal failure. We present the case of a patient with severe compromise of renal function secondary to deep infiltrating endometriosis with ureteral involvement. CASE REPORT: A 35-year-old woman with endometriosis presented with exacerbation of symptoms. Magnetic resonance showed deep pelvic endometriosis and intrinsic endometriotic involvement of the right distal ureter, causing a marked hydroureteronephrosis. Renal scintigram showed a severe compromise of the right renal function, with a relative function of 7%. Through laparoscopy a total right nephrectomy and resection of deep infiltrating endometriosis was performed. The patient had a satisfactory recovery in the postoperative period. CONCLUSIONS: Ureteral endometriosis presents a diagnostic and therapeutical challenge. Joint multidisciplinary management between radiologists, gynecologists and urologists through the design of an individualized surgical strategy is essential to define the optimal treatment for these patients.

Psychological Problems Experienced by Patients with Bowel Endometriosis Awaiting Surgery / Problemas psicológicos vivenciados por pacientes com endometriose intestinal aguardando cirurgia

Abstract Objective To assess the most common psychological disturbances in women with deep endometriosis and bowel involvement who are waiting surgical treatment and to evaluate what forms of coping are used to solve the problem. Methods This was a cross-sectional observational study of 40 women diagnosed with deep endometriosis and intestinal symptoms. They completed two questionnaires: one for anxiety and depression (Hospital Anxiety and Depression Scale [ HADS]) and the Scale of Mode of Confronting Problems (EMEP, in the Portuguese acronym). Results We found that 77.1% of the patients had anxiety and depression, with anxiety being the most prevalent (87.5% of the patients); 90% of the patients used problem focused and religious introspection as their main modes of confronting problems. Conclusion In the use of the HADS questionary, two psychological aspects were the most present in women with deep endometriosis awaiting surgical treatment: anxiety and depression. The most used forms of coping to solve the problem were problem coping and religious practices.

Resumo Objetivo Avaliar os distúrbios psicológicos mais comuns em mulheres com endometriose profunda e acometimento intestinal que aguardam tratamento cirúrgico e avaliar as formas de enfrentamento que são usadas para resolver o problema. Métodos Estudo observacional transversal com 40 mulheres com diagnóstico de endometriose profunda e acometimento intestinal. As pacientes responderam dois questionários: para ansiedade e depressão (Hospital Anxiety and Depression Scale [HADS, na sigla em inglês) e outro para enfrentamento dos problemas (EMEP). Resultados Constatamos que 77% das pacientess apresentaram ansiedade e depressão, sendo a ansiedade a mais prevalente (87,5%); 90% das pacientes usaram a forma religiosa e focada no problema como sua principal estratégia de enfrentamento. Conclusão Os aspectos psicológicos mais encontrados em mulheres com endometriose profunda e intestinal que aguardam tratamento cirúrgico são ansiedade e depressão. As formas mais usadas de enfrentamento para resolver o problema foram práticas religiosas e focada no problema.

Screening of Variants in the Transcript Profile of Eutopic Endometrium from Infertile Women with Endometriosis during the Implantation Window / Rastreio de variantes no perfil de tanscritos do endométrio eutópico de mulheres inférteis com endometriose durante a janela de implantação

Abstract Objective Abnormalities in the eutopic endometrium of women with endometriosis may be related to disease-associated infertility. Although previous RNA-sequencing analysis did not show differential expression in endometrial transcripts of endometriosis patients, other molecular alterations could impact protein synthesis and endometrial receptivity. Our aim was to screen for functional mutations in the transcripts of eutopic endometria of infertile women with endometriosis and controls during the implantation window. Methods Data from RNA-Sequencing of endometrial biopsies collected during the implantation window from 17 patients (6 infertile women with endometriosis, 6 infertile controls, 5 fertile controls) were analyzed for variant discovery and identification of functional mutations. A targeted study of the alterations found was performed to understand the data into disease's context. Results None of the variants identified was common to other samples within the same group, and no mutation was repeated among patients with endometriosis, infertile and fertile controls. In the endometriosis group, nine predicted deleterious mutations were identified, but only one was previously associated to a clinical condition with no endometrial impact. When crossing the mutated genes with the descriptors endometriosis and/or endometrium, the gene CMKLR1 was associated either with inflammatory response in endometriosis or with endometrial processes for pregnancy establishment. Conclusion Despite no pattern of mutation having been found, we ponder the small sample size and the analysis on RNA-sequencing data. Considering the purpose of the study of screening and the importance of the CMKLR1 gene on endometrial

Resumo Objetivo Anormalidades no endométrio eutópico de mulheres com endometriose podem estar relacionadas à infertilidade associada à doença. Embora a análise prévia de sequenciamento de RNA não tenha evidenciado expressão diferencial em transcritos endometriais de pacientes com endometriose, outras alterações moleculares poderiam afetar a síntese de proteínas e a receptividade endometrial. Nosso objetivo foi rastrear mutações funcionais em transcritos de endométrios eutópicos de mulheres inférteis com endometriose e de controles durante a janela de implantação. Métodos Os dados do sequenciamento de RNA de biópsias endometriais coletados durante a janela de implantação de 17 pacientes (6 mulheres inférteis com endometriose, 6 controles inférteis, 5 controles férteis) foram analisados para a descoberta de variantes e a identificação de mutações funcionais. Um estudo direcionado das alterações encontradas foi realizado para compreender os dados no contexto da doença. Resultados Nenhuma das variantes identificadas foi comuma outras amostras dentro do mesmo grupo, assim como nenhuma mutação se repetiu entre pacientes com endometriose, controles inférteis e férteis. No grupo de endometriose, foram identificadas nove mutações deletérias preditas, mas apenas uma foi previamente associada a uma condição clínica sem impacto endometrial. Ao cruzar os genes mutados com os descritores endometriose e/ou endométrio, o gene CMKLR1 foi associado a resposta inflamatória na endometriose e a processos endometriais para estabelecimento da gravidez. Conclusão Apesar de nenhum padrão de mutação ter sido encontrado, ponderamos o pequeno tamanho da amostra e a análise dos dados de sequenciamento de RNA. Considerando o objetivo do estudo de triagem e a importância do gene CMKLR1 na modulação endometrial, este poderia ser um gene candidato para estudos adicionais que avaliem mutações no endométrio eutópico de pacientes com endometriose.

Resonancia magnética en el estudio de dos pacientes con dolor pélvico crónico asociado a endometriosis de infiltración profunda / Magnetic resonance imaging in the study of two patients with chronic pelvic pain associated to infiltrating endometriosis deep

INTRODUCCIÓN: La endometriosis de infiltración profunda (EIP) es una enfermedad crónica de difícil diagnóstico, que frecuentemente es confundida con otras patologías pelvianas. OBJETIVO: Presentar dos casos de endometriosis de infiltración profunda, donde la resonancia magnética (RM) de pelvis, fue importante para el diagnóstico y planificación del tratamiento quirúrgico. CASO CLÍNICO: Se describe el caso de dos pacientes. La primera de 24 años afectada por un nódulo de EIP retrocervical con extensión intestinal sintomática y la segunda, una paciente de 37 años con una recidiva sintomática de EIP en la cúpula vaginal después de una histerectomía total. RESULTADOS: La RM de pelvis describe en ambos casos la extensión de las lesiones endometriósicas y presenta una excelente correlación con los hallazgos intra operatorios en la laparoscopía quirúrgica. CONCLUSIONES: La RM de pelvis es un excelente recurso en el estudio diagnóstico de las pacientes con dolor pélvico crónico, tanto en el caso de EIP retrocervical con extensión intestinal y también en la recidiva de EIP en la cúpula vaginal después de una histerectomía total

INTRODUCTION: Deep infiltration endometriosis (DIE) is a chronic disease of difficult diagnosis, which is frequently confused with other pelvic pathologies. OBJETIVE: To present two cases of deep infiltrating endometriosis, where the pelvic magnetic resonance imaging (MRI) was important in the diagnosis and surgical treatment planning. CLINICAL CASES: Two cases, one 24 years-old patient suffering from retrocervical DIE nodule with symptomatic bowel involvement, and a 37 years-old patient, with a symptomatic DIE at the vaginal cuff after total hysterectomy. RESULTS: Pelvic MRI describes in both cases the extension of the endometriotic lesions and presents an excellent correlation with the intra operatory findings during surgical laparoscopy. CONCLUSIONS: Pelvic MRI is an excellent diagnostic tool for patients with pelvic pain, in case of retrocervical DIE with bowel involvement, and also in recurrence of DIE at the vaginal cuff after total hysterectomy

Tratamiento multidisciplinario de la endometriosis profunda grave / Multidisciplinary treatment of severe deep endometriosis

Introducción: La endometriosis es una entidad clínica caracterizada por la presencia de tejido endometrial fuera del endometrio, siendo la afección rectocolónica más agresiva. Diseño: Retrospectivo de grupo único. Objetivos: Evaluar la factibilidad de las resecciones colorrectales, patología compleja que debe abordarse en forma multidisciplinaria y reportar los resultados obtenidos de más de 10 años de trabajo. Material y métodos: Estudio descriptivo y retrospectivo de una serie de casos. En el periodo comprendido entre 2005 y a principios de 2017, se evaluaron 29 pacientes. La evaluación se realizó en forma multidisciplinaria. Resultados: Hemos operado 171 endometriosis profundas. La edad media fue 34,04 años. Veintinueve necesitaron resección de colon, en 27 se realizó una resección anterior con anastomosis colorrectal y 2 sigmoidectomías. Las anastomosis fueron con sutura mecánica, 17 término-terminales colorrectales y 12 término-laterales. Veintiocho anastomosis fueron realizadas entre los 7 y 5 cm del margen anal, 1 fue realizada a 4 cm del margen anal. En este caso se confeccionó una colostomía transversa de protección. El tiempo operatorio medio fue 90 minutos (45-195). El índice de conversión fue del 15%. Las complicaciones fueron hemoperitoneo, fístula anastomótica e infecciones de piel. La estadía institucional la media fue de 5 días. Conclusiones: El tratamiento laparoscópico de esta enfermedad es factible, debido a la distorsión de la anatomía de la pelvis que esta genera, aunque las tendencias actuales enfatizan la necesidad del tratamiento de esta afección de forma mínimamente invasiva. (AU)

Introduction: Endometriosis is a clinical entity characterized by the presence of endometrial tissue outside the endometrium, being the most aggressive rectocolonic condition. Design: Descriptive, retrospective case series study. Objective: Evaluate the feasibility of colorectal resections in this complex pathology that must be approached in a multidisciplinary way and report the results obtained from more than 10 years of work. Material and methods: In the period between 2005 and early 2017, 29 patients were evaluated in a multidisciplinary way. Results: One hundred and seventy-one patients were operated on for deep endometriosis, mean age 34 years. Twenty-nine patients required colon resection, 27 anterior resection and 2 sigmoidectomies. Seventeen end-to-end and 12 end- to- side stapled anastomoses were performed. Twenty-eight anastomoses were performed between 7 and 5 cm from the anal margin and one at 4 cm. In the latter, a protective transverse colostomy was made. The mean operative time was 90 (45-195) minutes. The conversion rate was 15%. Complications were hemoperitoneum, anastomotic fistula, and wound infections. The average hospital stay was 5 days. Conclusion: Laparoscopic treatment of this disease is feasible. Despite the distortion it generates in the anatomy of the pelvis, the current trend emphasizes the need for minimally invasive treatment. (AU)

Is there an Increased Risk for unfavorable obstetric outcomes in women with endometriosis? an evaluation of evidences / Existe um risco maior para desfechos obstétricos desfavoráveis em mulheres com endometriose? uma avaliação das evidências

Abstract Objective The present study is a systematic review of the literature to assess whether the presence of endometriosis determines or contributes to adverse obstetric outcomes. Data Sources The present work was carried out at the Hospital Israelita Albert Einstein, São Paulo, state of São Paulo, Brazil, in accordance to the PRISMA methodology for systematic reviews. A review of the literature was performed using PubMed, Web of Science and Scopus databases. The keywords used were: pregnancy outcome, pregnancy complications, obstetrical complications, obstetrics, obstetric outcomes and endometriosis. The survey was further completed by a manually executed review of cross-referenced articles, which was last performed on November 30, 2018. Selection of studies The survey disclosed a total of 2,468 articles, published from May 1946 to October 2017. A total of 18 studies were selected to be further classified according to their quality and relevance. Data Collection The Newcastle-Ottawa Quality Assessment Scale was used for classification. Five studies of greater impact and superior evidence quality and 13 studies of moderate evidence quality were selected. We analyzed the studies for the characteristics of their patients plus how endometriosis was diagnosed and their respective obstetric outcomes taking into account their statistical relevance. Data Synthesis Analyses of the higher impact and better quality studies have shown high incidence of preterm birth and placenta previa in patients with endometriosis. Conclusion Placenta previa and preterm birth are the most statistically significant outcomes related to endometriosis, as indicated by our systematic review. The present information is useful to alert obstetricians and patients about possible unfavorable obstetric outcomes.

Resumo Objetivo Realizar uma revisão sistemática e crítica da literatura de modo a avaliar se a presença de endometriose determina desfechos obstétricos adversos na gestação. Fonte dos dados O presente estudo foi realizado no Hospital Israelita Albert Einstein, São Paulo, SP, Brasil, de acordo com a metodologia PRISMA para revisões sistemáticas. As bases de dados usadas para a revisão de literatura foram Pubmed, Web of Science e Scopus. As palavras-chave usadas foram: pregnancy outcome, pregnancy complications, obstetrical complications, obstetrics, obstetric outcomes e endometriosis. Uma revisão manual de artigos com referências cruzadas completou a pesquisa, que foi realizada pela última vez em 30 de novembro de 2018. Seleção dos estudos A pesquisa contou com o total de 2.468 artigos, publicados de maio de 1946 a outubro de 2017. Foram selecionados 18 estudos com base em sua relevância. Coleta de dados A metodologia Newcastle-Ottawa Quality Assessment Scale foi usada para selecionar 5 estudos cuja evidência era de melhor qualidade e 13 estudos de moderada qualidade de evidência. As características das populações dos estudos foram analisadas, assim como a doença endometriose foi diagnosticada e os respectivos desfechos obstétricos nas pacientes observando-se a relevância estatística dos estudos. Síntese dos dados A análise dos estudos de maior impacto e de melhor qualidade de evidência mostram que placenta prévia e ocorrência de nascimentos pré-termo são os desfechos obstétricos desfavoráveis de maior incidência em pacientes com endometriose. Conclusão Placenta prévia e nascimentos pré-termo são os desfechos obstétricos com maior significância estatística relacionados à endometriose. Esta informação é útil para alertar obstetras e pacientes com endometriose para possíveis desfechos obstétricos desfavoráveis.

Analysis of body composition and pain intensity in women with chronic pelvic pain secondary to endometriosis / Análise da composição corporal e intensidade de dor em mulheres com dor pélvica crônica secundária a endometriose

Abstract Objective To determine the average body composition (percentage of body fat), the anthropometric markers, and the intensity of clinical pain in women with a clinical diagnosis of chronic pelvic pain (CPP) secondary to endometriosis. Methods A case-control study performed with 91 women, 46 of whom with CPP secondary to endometriosis and 45 of whom with CPP secondary to other causes. They underwent an evaluation of the anthropometric parameters by means of the body mass index (BMI), the perimeters (waist, abdomen, hip), and the percentage of body fat (%BF), which were assessed on a body composition monitor by bioimpedance; the intensity of the clinical pain was evaluated using the visual analog scale (VAS), and the symptoms of anxiety and depression, using the hospital's anxiety and depression scale (HAD). Results The groups did not differ in terms of mean age, BMI, %BF or regarding the available waist-to-hip ratio (WHR). The mean intensity of the clinical pain by the VAS was of 7.2 ± 2.06 in the group with CPP secondary to endometriosis, and of 5.93 ± 2.64 in the group with CPP secondary to other causes (p = 0.03), revealing significant differences between the groups. Conclusion We concluded that, despite the difference in the pain score assessed between the two groups, there was no difference regarding body composition and anthropometry.

Resumo Objetivo Determinar a composição corporal média (porcentagem de gordura corporal), os marcadores antropométricos, e a intensidade de dor clínica em mulheres com diagnóstico clínico de dor pélvica crônica (DPC) secundária a endometriose. Métodos Um estudo de caso-controle realizado com 91 mulheres, 46 das quais com DPC secundária a endometriose, e 45 das quais com DPC secundária a outras causas. As pacientes foram submetidas à avaliação dos parâmetros antropométricos por meio do índice de massa corporal (IMC), dos perímetros (cintura, abdômen, quadril), e do percentual de gordura corporal (%GC), que foram avaliados emmonitor de composição corporal por bioimpedância; a intensidade clínica da dor foi avaliada usando-se a escala visual analógica (EVA), e os sintomas de ansiedade e depressão, usando a escala de ansiedade e depressão do hospital (EADH). Resultados Os grupos não diferiram quanto à idade média, ao IMC, ao %GC, nem quanto à relação da cintura-quadril (RCQ) disponível. Amédia da intensidade clínica da dor pela EVA foi de 7,2 ± 2,06 no grupo com DPC secundária a endometriose, e de 5,93 ± 2,64 no grupo com DPC secundária a outras causas (p = 0,03), revelando diferenças significativas entre os grupos. Emrelação à EADH, ambos os grupos estavam acima da média de corte. Conclusão Concluímos que, apesar da diferença no escore de dor avaliado entre os dois grupos, não houve diferença com relação à composição corporal e à antropometria.

Endometriosis del apéndice cecal como causa de dolor abdominal crónico y masa apendicular / Appendiceal endometriosis as a cause of chronic abdominal pain and appendiceal mass

Presentamos el caso de una paciente en edad reproductiva con dolor abdominal crónico y antecedente de endometriosis pelviana. Los estudios por imágenes muestran masa en topografía apendicular. Se decidió exploración laparoscópica programada y se realizó la resección del tumor apendicular. La anatomía patológica mostró endometriosis del apéndice cecal. Posteriormente se realiza una revisión bibliográfica de esta patología y se hacen consideraciones sobre su frecuencia, presentación clínica, hallazgos intraoperatorios, forma de estudio y posibilidades terapéuticas.

We report the case of a female patient in childbearing age with chronic pain and a history of pelvic endometriosis. The image tests showed the presence of a mass at the level of the cecal appendix. The patient underwent a scheduled diagnostic laparoscopy and the appendiceal tumor was resected. The pathological examination revealed appendiceal endometriosis. We performed a review of the literature and made considerations about its prevalence, clinical presentation, interoperative findings, diagnostic tests and therapeutic management.

Quality of life assessment by the endometriosis health profile (EHP-30) questionnaire prior to treatment for ovarian endometriosis in brazilian women / Avaliação da qualidade de vida através do questionário Endometriosis Health Profile (EHP-30) antes do tratamento da endometriose ovariana em mulheres Brasileiras

Abstract Objective To evaluate the existence of an association between ultrasound findings and epidemiological and clinical factors using results obtained from the EHP-30 questionnaire in women with ovarian endometriosis. Methods A cross-sectional observational study was performed between July 2012 and May 2015, in which patients with chronic pelvic pain suggestive of endometrioma, as indicated by the results from a transvaginal pelvic ultrasonography, completed the standardized Endometriosis Health Profile - 30 (EHP-30) questionnaire to access quality-of-life scores before beginning treatment for endometriosis. A total of 65 patients were included. The data was analyzed in the statistical program IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA) for the comparison of data through linear multiple regression. Results The suitability of the linear regression model was confirmed by the histogram of the dependent variable and the residue distribution plot, confirming the trend of linearity as well as the homogeneous dispersion of the residues. The mean age of the patients was 39.7 ± 7.1 years old. Themajority was Caucasian (64.5%), had completed higher education (56.5%) and was nulligravida (40.3%). Infertility was present in 48.4% of the patients studied. Out of the total sample, 80.6% of the cases were symptomatic and complained mainly of acyclic pain, 79% of dysmenorrhea, and 61.3% of dyspareunia. This reflects the negative influence of endometriosis on the quality of life of patients with this disease. Conclusion Dyspareunia and acyclic pain were independent factors of correlation with high scores in the EHP-30 questionnaire, reflecting a worse quality of life.

Resumo Objetivo Avaliar a existência de associação entre os achados ultrassonográficos e os fatores epidemiológicos e clínicos com os resultados obtidos no questionário EHP-30 em mulheres com diagnóstico de endometriose ovariana. Métodos Realizou-se um estudo observacional transversal entre julho de 2012 emaio de 2015, no qual as pacientes com dor pélvica crônica com imagem sugestiva de endometrioma na ultrassonografia pélvica transvaginal preencheram o questionário padronizado Endometriosis Health Profile - 30 (EHP-30) para acessar os escores de qualidade de vida antes de iniciar qualquer tratamento para a endometriose. Foram incluídas 65 pacientes. Os dados foram analisados no programa estatístico IBM SPSS Statistics for Windows, Versão 22.0 (IBM Corp., Armonk, NY, EUA) para a comparação dos dados através de regressão múltipla linear. Resultados A adequabilidade do modelo de regressão linear foi confirmada através do histograma da variável dependente e do gráfico de distribuição dos resíduos, confirmando a tendência de linearidade, assim como a dispersão homogênea dos resíduos. A idade média das pacientes foi de 39,7 ± 7,1 anos. Amaioria era caucasiana (64,5%), apresentava ensino superior completo (56,5%), e era nuligesta (40,3%). Infertilidade estava presente em 48,4% das pacientes estudadas. Do total de casos 80,6% eram sintomáticas e queixaram-se principalmente de dor acíclica, 79%de dismenorreia , e 61,3% de dispareunia em , refletindo a influência negativa da endometriose sobre a qualidade de vida das pacientes portadores desta doença. Conclusão Dispareunia e dor acíclica foram fatores independentes de correlação com altos escores no EHP-30, refletindo uma pior qualidade de vida.

Tratamiento quirúrgico de la endometriosis pélvica profunda con compromiso colorrectal / Surgical treatment of deep pelvic endometriosis with colorectal involvement

INTRODUCCIÓN: En la endometriosis el compromiso intestinal afecta hasta al 12% de las pacientes, comprometiendo al recto y a la unión rectosigmoidea en el 90% de los casos. OBJETIVO: Describir la experiencia del equipo de Coloproctología y Ginecología de Clínica Alemana de Santiago en el tratamiento quirúrgico de la endometriosis pélvica profunda con compromiso colorrectal. MATERIAL Y MÉTODOS: Estudio retrospectivo a partir de la base de datos de pacientes con endometriosis tratados entre enero del año 2015 y abril de 2018. Los criterios de inclusión fueron pacientes con clínica de endometriosis pélvica profunda, que tuviesen compromiso colorrectal y hayan sido tratados con shaving rectal, resección discoide o resección segmentaria. Se revisaron fichas clínicas electrónicas, protocolos operatorios y biopsias definitivas. RESULTADOS: Se reclutaron 25 pacientes con una mediana de edad de 35 años. El síntoma principal de consulta fue dismenorrea y el síntoma digestivo más frecuente fue disquecia. En 8 pacientes se realizó un shaving rectal, en 7 una sigmoidectomía, en 9 una resección discoide y en 1 paciente una tiflectomía. La complicación posoperatoria reportada fue la hemorragia digestiva baja en 4 pacientes (Clavien-Dindo I y IIIa). Con una mediana de seguimiento de 13 meses, a la fecha 3 pacientes se les ha diagnosticado algún tipo de recidiva. CONCLUSIÓN: Es importante que la cirugía a realizar, garantice una morbilidad y recurrencia baja. Los resultados en nuestro centro son alentadores, lo que nos hace creer que el tratamiento quirúrgico podría ser una buena alternativa en la endometriosis pélvica profunda con compromiso colorrectal.

INTRODUCTION: In endometriosis, intestinal involvement affects up to 12% of patients, compromising the rectum and the rectosigmoid junction in 90% of cases. AIM: Describe the experience of the Coloproctolgy and Gynecology Team of the Clínica Alemana de Santiago in the surgical treatment of deep pelvic endometriosis with colorectal involvement. MATERIAL AND METHODS: Retrospective study based on the database of patients with endometriosis treated between January 2015 and April 2018. The inclusion criteria were patients with deep pelvic endometriosis clinic, who had colorectal involvement and who had been treated with rectal shaving, discoid resection or segmental resection. Electronic clinical records, operative protocols and definitive biopsies were reviewed. RESULTS: Twenty-five patients with a median age of 35 years were recruited. The main symptom of consultation was dysmenorrhoea and the most frequent digestive symptom was dyschezia. In 8 patients a rectal shaving was performed, in 7 a sigmoidectomy, in 9 a discoid resection and in 1 patient a tiflectomy. The only reported post-operative complication was low gastrointestinal bleeding in 4 of the 25 patients (Clavien-Dindo I and IIIa). A median follow-up of 13 months was achieved, to date 3 patients have been diagnosed with some type of recurrence. CONCLUSION: It is important that the surgery to be performed guarantees low morbidity and recurrence. The results in our center are encouraging, which makes us believe that surgical treatment could be a good alternative in deep pelvic endometriosis with colorectal involvement.

Angiomixoma pélvico asociado a endometriosis infiltrativa profunda: reporte de un caso / Pelvic angiomyxoma associated to deep infiltrative endometriosis: case report

El angiomixoma de la pelvis es un tumor mesenquimal inusual; que dado su alto potencial de recidiva es relevante que la exéresis quirúrgica sea lo más radical posible. Por su parte, la endometriosis infiltrativa profunda, es otra entidad poco frecuente que requiere de tratamientos complejos. La co-existencia de ambas patologías representa una situación absolutamente infrecuente; de los que hay muy pocos casos reportado en la literatura occidental. Se presenta el caso de una mujer de 41 años de edad que desarrolló ambas entidades nosológicas de forma concomitante y que fue tratada quirúrgicamente con buenos resultados.

Angiomyxoma of the pelvis is an unusual mesenchymal tumor; that given its high potential for recurrence, it is relevant that the surgical resection be as radical as possible. For its part, to deep infiltrative endometriosis is another rare entity that requires complex treatments. The co-existence of both pathologies represents an absolutely infrequent situation; of which there are very few cases reported in western literature. We present the case of a 41-year-old woman who developed both clinical entities concomitantly and who was treated surgically with good results.