[How does peritoneal fluid flow influence anatomical distribution of endometriotic lesions?]. / Etude de la distribution anatomique des lésions endométriosiques: un argument majeur en faveur de la participation de la théorie de la régurgitation dans la physiopathologie de l'endométriose.

Endometriosis is a common disease in gynecology. Many theories were proposed to explain the endometriosis pathogenesis. The distribution of the endometriosis lesions seems to be interesting in order to understand the endometriosis pathogenesis. This distribution is asymmetric. This asymmetric distribution of endometriosis is explained by the anatomy of the peritoneal cavity and by the intraperitoneal fluids. It strongly confirms the role of menstrual regurgitation and peritoneal fluid in the endometriosis genesis. The similar asymmetric distribution for all types of endometriosis (superficial lesions, ovarian endometriosis cyst, deep endometriosis) is an argument in favor of a unique origin for the different types of lesions.

Uterine myometrium as a cell patch as an alternative graft for transplantation to infarcted cardiac myocardium: a preliminary study.

PURPOSE: Currently, only a small fraction of patients are able to receive reperfusion therapy for myocardial infarctions. We hypothesize that myometrial cell patch transplantation could be an alternative approach for the treatment of myocardial infarction. DESIGN: We performed a preliminary study to determine the feasibility of this novel therapeutic approach in a rabbit model. PROCEDURES: Six adult female New Zealand rabbits were used. Myocardial infarction was induced by left anterior descending artery ligation. A segment of uterus was removed via a laparotomy incision, and this uterine segment was transplanted as an autologous graft over the infarcted myocardium, which was then reinforced by greater omentum. Statistical methods and outcome measures: Hemodynamic measurements and histological studies. MAIN FINDINGS: All uterine myometrial patches survived in the test animals. Fluoroscopic hemodynamic measurements were made for ejection fractions at 8 weeks after the application of the uterine patch. Histological study demonstrated well-healed myometrial-myocardium junctions with minimum scar tissue. Angiogenesis occurred in the transplanted myometrium. Connexin 43 expression was demonstrated in the transplanted patches. CONCLUSION: Our noncontrolled preliminary rabbit experiments indicate that patches of uterine myometrium reinforced by greater omentum can be used as autologous transplant therapy for infracted myocardium. This is an innovative technique that could lead to future treatment for individuals who may suffer from an infarcted myocardium and may not be eligible for traditional reperfusion therapy.

Müllerianosis.

Müllerianosis may be defined as an organoid structure of embryonic origin; a choristoma composed of müllerian rests--normal endometrium, normal endosalpinx, and normal endocervix--singly or in combination, incorporated within other normal organs during organogenesis. A choristoma is a mass of histologically normal tissue that is "not normally found in the organ or structure in which it is located" (Choristoma, 2006). Müllerian choristomas are a subset of non-müllerian choristomas found throughout the body. Histologically, endometrial-müllerianosis and endometriosis are both composed of endometrial glands and stroma, but there the similarity ends. Their pathogenesis is different. Sampson faced the same difficulty with pathogenesis and nomenclature when he wrote: "The nomenclature of misplaced endometrial or müllerian lesions is a difficult one to decide upon." "The term müllerian would be inclusive and correct, but unfortunately it suggests an embryonic origin." Sampson then divided "misplaced endometrial or müllerian tissue" into "four or possibly five groups, according to the manner in which this tissue reached its ectopic location" (Sampson, 1925). Sampson's classification of heterotopic or misplaced endometrial tissue is based on pathogenesis: 1) "direct or primary endometriosis" [adenomyosis]; "a similar condition occurs in the wall of the tube from its invasion by the tubal mucosa" [endosalpingiosis]; 2) "peritoneal or implantation endometriosis;" 3) "transplantation endometriosis;" 4) "metastatic endometriosis;" and 5) "developmentally misplaced endometrial tissue. (I admit the possibility of such a condition, but have never been able to appreciate it.)" (Sampson, 1925). It is precisely this condition "developmentally misplaced endometrial tissue," [müllerianosis] that is the subject of this review.

Expression of AhR and ARNT mRNA in cultured human endometrial explants exposed to TCDD.

Endometriosis is a debilitating disease found in 10-15% of reproductive-age women and is characterized by the presence of endometrial tissue outside of the uterus. The present study characterizes the expression of AhR and ARNT mRNA in a human endometrial explant culture model in the absence and presence of TCDD exposure. In a parallel, companion study using this model, TCDD exposure was shown to induce CYP1A1 mRNA, CYP1B1 mRNA, EROD (7-ethoxyresorufin-O-deethylase) activity, and CYP1B1 protein in human endometrial explants. Explants were prepared from specimens obtained at laparoscopy or laparotomy from women undergoing surgery for tubal ligation, endometriosis, or pelvic pain unrelated to endometriosis. These specimens were a subset of the specimens used in the parallel study. The explants were cultured in medium containing 10 nM estradiol (E(2)) or 1 nM estradiol plus 500 nM progesterone (E(2) + P(4)) with or without TCDD (first 24 h). After culture, AhR and ARNT mRNA expression were quantified by RT-PCR. TCDD treatment significantly increased the expression of AhR mRNA, but not ARNT mRNA. The expression of both genes was similar for all individual explants and the ratio of AhR:ARNT mRNA expression across all samples was 1.7 to 1.8. Constitutive AhR mRNA expression was donor age dependent (increasing with age), while ARNT mRNA expression was donor age and tissue phase dependent (increased in older and proliferative phase specimens). Similar to results in the parallel study on expression of CYP1A1 mRNA, CYP1B1 mRNA, EROD activity, and CYP1B1 protein, the presence of endometriosis did not affect the expression of AhR or ARNT mRNA, either constitutively or following TCDD exposure. However, the detection of disease-specific change was limited by small sample size and variability in tissue cycle phase. The human endometrial explant culture model will be useful for future studies of the effects of dioxin-like compounds on human endometrium in relationship to cycle phase, hormonal exposure, and donor age.

Effect of TCDD exposure on CYP1A1 and CYP1B1 expression in explant cultures of human endometrium.

Endometriosis is a debilitating disease estimated to affect 10% of reproductive-age women and characterized by the growth of endometrial tissue outside of the uterus. The present study characterizes a human endometrial explant culture model for studying the direct effects of TCDD exposure by assessing the expression of CYP1A1 and CYP1B1 mRNA (Northern blotting), protein (Western blotting), and activity (7-ethoxyresorufin-O-deethylase; EROD) in explants cultured with and without TCDD. Explants were obtained at laparoscopy or laparotomy from women undergoing surgery for tubal ligation, endometriosis, or pelvic pain unrelated to endometriosis. The explants were cultured with 10 nM estradiol (E(2)) or 1 nM E(2) plus 500 nM progesterone (P(4)) with or without TCDD (first 24 h). The expression of CYP1A1 and CYP1B1 mRNA was greatest with 10 nM TCDD and increased up to 72 h after initial exposure. EROD activity increased up to 120 h. Explants from a secretory phase biopsy became reorganized in culture and formed a new epithelial membrane, while maintaining basic endometrial morphology and viability for up to 120 h. At 24 h, TCDD significantly increased CYP1A1 and CYP1B1 mRNA, and at 72 h, TCDD significantly increased EROD activity and CYP1B1 protein compared to explants cultured without TCDD for similar times. CYP1B1 protein also exhibited substantial constitutive expression that was similar in uncultured biopsies, where CYP1B1 protein was immunolocalized in the cytoplasm of epithelial glands, with only occasional patches of protein in the surface epithelial membrane. In explants cultured with and without TCDD exposure, CYP1B1 protein was localized in the cytoplasm of the new surface epithelial membrane and glands closest to the surface. CYP1A1 protein was not detected in uncultured biopsies or explants. Both younger age (age 30 and under) and proliferative phase were associated with higher TCDD-induced EROD activity in specimens treated with E(2):P(4). No significant endometriosis-related differences were observed for any of the biomarkers, but the detection of disease-specific change was limited by small sample size and variability in tissue-cycle phase. The human endometrial explant culture model will be useful for future studies of the effects of dioxin-like compounds on human endometrium in relationship to cycle phase and hormonal exposure.

Postmenarchal development of chylous ascites in acrocephalosyndactyly with congenital lymphatic dysplasia.

BACKGROUND: Acrocephalosyndactyly is a syndrome characterized by congenital malformation of the skull with craniosynostosis, midface hypoplasia, and symmetrical webbed fusion of the fingers and toes. We describe a possible pathophysiologic mechanism for chylous ascites that developed several months after menarche in a woman with acrocephalosyndactyly and congenital lymphatic dysplasia. CASE: A 25-year-old nulligravid woman with acrocephalosyndactyly, at 18 months after menarche, developed persistent abdominal distension at age 18 years. Laparoscopy at age 25 years revealed chylous ascites with marked chronic peritoneal inflammation, and lymphatic dysplasia with lymphocysts. With hormone manipulation, the chylous ascites fluctuated. CONCLUSION: After menarche in a woman with acrocephalosyndactyly, ovarian steroid hormones might have increased lymph production and hydrostatic pressure, causing rupture of congenitally dysplastic lymph vessels resulting in chylous ascites.

Communication and documentation before and after laparoscopic surgery.

Increasingly, sanctions by Offices of Professional Medical Conduct, functioning at state level, and malpractice suits are being used to discipline physicians. A system of documentation and communication, practiced successfully for more than 30 years, can reduce the risk of such actions. (J Am Assoc Gynecol Laparosc 6(4):379-381, 1999)

Health and fertility outcomes among women surgically treated for endometriosis.

STUDY OBJECTIVE: To assess health and fertility status among women after surgical treatment of endometriosis. DESIGN: Prospective study. SETTING: Community-based gynecologic specialty practice. PATIENTS: Two hundred ninety women with newly diagnosed endometriosis. MEASUREMENTS AND MAIN RESULTS: Medical records of all women were abstracted at baseline; self-administered questionnaires were used to collect follow-up data. Most women (68-79%) reported some or great improvement in symptomology after surgical treatment. One hundred twenty-four (53%) of 232 women reported one or more pregnancies, two-thirds of which resulted in live births. Secondary sex ratios were below 1 (range 0.92-0.50), reflecting a female excess. Logistic regression analysis identified previous live birth as the only significant predictor of pregnancy after surgery; advancing maternal age significantly decreased the likelihood of a live birth. CONCLUSIONS: Overall, these women reported improvement in symptoms at follow-up. Operative and clinical findings were not significant predictors of pregnancy likelihood. Prior live birth conferred more than a twofold increase in pregnancy likelihood, whereas advancing age decreased the likelihood. Reasons for reversed sex ratios are unknown but warrant further study.

Life-style factors and female infertility.

We summarize the epidemiologic literature on the effect of life-style factors such as cigarette smoking, alcohol and caffeine consumption, physical exercise, body mass index, and drug use on female infertility. We identified relevant papers through MEDLINE, Index Medicus, and a manual review of reference lists. Risk factors that affect the risk of primary tubal infertility and that were corroborated in two or more studies include use of intrauterine devices (especially the Dalkon Shield) and cigarette smoking. We identified extremes in body size as a risk factor for primary ovulatory infertility. Cocaine, marijuana and alcohol use, exercise, caffeine consumption, and ever-use of thyroid medications were possible risk factors for various subtypes of primary infertility. Few risk factors have been assessed or identified for secondary infertility or other less common subtypes, such as cervical or endometriosis-related infertility.

Sexual activity, contraception, and reproductive factors in predicting endometriosis.

To examine the belief that women with endometriosis have "voluntarily" delayed childbirth, the authors used a case-control approach to assess the relation between sexual, contraceptive, and reproductive factors and endometriosis. A total of 104 laparoscopically confirmed newly diagnosed cases of endometriosis were identified from a gynecologic specialty clinic in western New York state in 1987. Two control groups were used: 1) 100 friend controls, and 2) 98 medical controls. No differences were found between study groups on use of reliable birth control, use of birth control before a first pregnancy, age at first intercourse, frequency of intercourse, decisions to delay pregnancy, age at first pregnancy, or measures of body size. Cases were older than medical controls by about 1 year when they first began using birth control (19.8 vs. 18.6 years, p < 0.05). Cases were also 1 year older than friend controls when they began regular intercourse (20.9 vs. 19.5 years, p < 0.005) and at first marriage (22.8 vs. 21.7 years, p < 0.05). A larger percentage of cases than friend controls were never pregnant (p < 0.0001) and were more likely to have problems becoming pregnant (p < 0.0001). Results, overall, do not support simplistic assumptions that characterize endometriosis patients as career women who voluntarily delay pregnancy. Rather, the results point to a complex relation between endometriosis and reproductive, sexual activity, and fertility-related factors.

Endometriosis and body fat distribution.

OBJECTIVE: To examine the association of body fat distribution with risk of endometriosis in an effort to determine whether a specific somatotype is related to the disease. METHODS: We conducted a case-control study of 88 laparoscopically confirmed cases of endometriosis, identified in a specialty gynecologic practice in western New York, and 88 age-matched friend controls. Data were collected by standardized personal interview, and body measurements were taken in a standardized fashion by one interviewer. Risk of endometriosis associated with body fat distribution, as expressed by waist-to-hip and waist-to-thigh ratios, was assessed using logistic regression. RESULTS: For women under 30 years of age (45 cases, 46 controls), endometriosis was inversely related to both waist-to-hip ratio (odds ratio 6.18, 95% confidence interval [CI] 2.01-19.01) and waist-to-thigh ratio (odds ratio 3.64, 95% CI 1.23-10.78). This effect was not evident among women aged 30 years and older (43 cases, 42 controls). CONCLUSION: Our results suggest a specific somatotype with a predominance of peripheral body fat among women with endometriosis. This finding may provide information useful in both the diagnosis and understanding of the disease etiology.

Menstrual cycle characteristics and the risk of endometriosis.

The present study utilized a case-control design to assess the relation between menstrual cycle factors and risk of endometriosis in women age 19-45 years. From a gynecologic specialty clinic in Western New York in 1987, we identified 104 laparoscopically confirmed cases of endometriosis. We used two control groups: (1) 100 friend controls (friends of cases), and (2) 98 medical controls (patients from the same medical practice with conditions other than endometriosis). Controls were frequency matched to cases by age. Because crude odds ratios (ORs), stratified by age (< 30 vs > or = 30 years), revealed effect modification by age, we performed all analyses by age group. We used logistic regression to calculate ORs and 95% confidence intervals (CIs), controlling for pregnancy, religion, and body mass index. Among women under age 30, using friend controls, we observed elevated risks for menstrual flow > or = 6 days per month (OR = 2.5, 95% CI = 1.1-5.9), heavy flow (OR = 2.5, 95% CI = 1.1-6.3), severe cramps (OR = 2.5, 95% CI = 1.2-6.0), increasing symptoms (OR = 6.6, 95% CI = 2.6-16.5), and tampon use > or = 14 years (OR = 3.6, 95% CI = 1.04-13.5). Risks were also elevated for women age 30 and over, but not to the same degree as among younger women.(ABSTRACT TRUNCATED AT 250 WORDS)

Jordan M. Phillips, M.D.--postdoctoral educator at large.

Twenty years ago Jordan Phillips recognized the importance of laparoscopy and aroused the interest of gynecologists by founding the American Association of Gynecologic Laparoscopists (AAGL). Within five years he had expanded the teaching mission of the AAGL to microsurgery, which revolutionized infertility surgery. Through his insatiable personal drive, he catalyzed the movement of people and ideas on an international level by organizing numerous postgraduate courses in North America, Europe and Asia, and later Australia and South America. Through his untiring efforts as an educator, Jordan Phillips has played a major role in preparing gynecologists in many parts of the world for the commanding position of advanced laparoscopic surgery, hysteroscopy and microsurgery in gynecologic practice.

Labor and delivery events and risk of sudden infant death syndrome (SIDS)

The purpose of this study was to assess whether labor and delivery events were risk factors for sudden infant death syndrome (SIDS). A nested case-control design was used. From the 1974 cohort of live births for Upstate New York (exclusive of New York City), resident mothers (n = 132,948), SIDS cases, and living controls were selected. Data were abstracted from hospital delivery and vital records for 148 autopsied cases and 355 frequency-matched controls. With the use of unconditional logistic regression, no increase in SIDS risk was observed for artificial rupture of membranes, medication use during labor, induction/augmentation of labor, or anesthesia for delivery. An increased risk of SIDS was observed for labor 16 hours or more (odds ratio (OR) = 2.6, 95% confidence interval (CI) 1.1-6.5) and vaginal breech delivery (OR = 7.2, 95% CI 0.7-72.2). Significant inverse trends were observed for Apgar scores and risk of SIDS.