SF-36 preoperative interest of predicting improvement of quality of life after laparoscopic management of minimal endometriosis.

THE PURPOSE OF THE STUDY: To study preoperative thresholds of the SF-36 components above which we can predict a high risk of failure in order to improve the quality of life after surgery for patients with minimal endometriosis. MATERIAL AND METHODS: Design: prospective and multicenter observational study between February 2004 and 2011. PATIENTS: 167 patients with operated minimal endometriosis. SETTING: for the Physical Component Summary (PCS) or the Mental Component Summary (MCS) subscales of the SF-36 questionnaire, an improvement defined by an increase of 5 points. INTERVENTION: evaluation by the SF-36 questionnaire the week before and one year after surgery. MEASUREMENT AND MAIN RESULTS: Success of surgery measured by an improvement in both components. We found significantly different initial variables between patients with improvement and those without: initial MCS score (P=0.0003), initial PCS score (P<0.0001) and dyspareunia (P=0.004). Multivariate analysis revealed only two significant variables. Initial MCS higher than 40 (OR=4.6) and initial PCS higher than 50 (OR=10.6) are risk factors for failure of improvement after surgery. CONCLUSION: Surgery is seldom a good treatment for improving QOL in minimal endometriosis. We set two thresholds for SF-36, 50 for PCS and 40 for MCS: above there is a very high risk of failure (86% of failure in our population). Under, the risk of failure remains high (54.3%). CANADIAN TASK FORCE CLASSIFICATION OF STUDY DESIGN: Evidence obtained from well-designed cohort or case-control studies, preferably from more than one center or research group.

[Don't forget fallopian tubes! A morphologic and immunohistochemical study about Fallopian tubes with genetic risk (BRCA mutation)]. / N'oubliez pas les trompes ! Étude morphologique et immunohistochimique des trompes à risque génétique (mutation BRCA).

OBJECTIVES: The objective of this study was to describe morphologic and immunohistochemical features of precursor tubal lesions in prophylactically removed Fallopian tubes. PATIENTS AND METHODS: Hundred and forty-seven bilateral salpingectomies (genetic predisposition or group A: n=57; and control group or group B: n=90) were reviewed by two pathologists blinded to clinical data. Seven epithelial cytological and architectural features were studied to compare the degree of tubal epithelial abnormalities between the two groups. Immunohistochemical expression patterns of Ki67 and p53 were also evaluated. RESULTS: Serous tubal intraepithelial lesions (STIL) have been identified in group A with stronger expression for Ki67 and p53 (especially in BRCA 1 group) than in group B. DISCUSSION AND CONCLUSION: The current results show the importance of salpingo-oophrectomy in BRCA mutation carriers and the complete histopathological sampling of the Fallopian tubes.

[Endometriosis and postoperative infertility. A prospective study (Auvergne cohort of endometriosis)]. / Endométriose et fertilité postopératoire. Étude prospective d'après les données de la cohorte Auvergne.

OBJECTIVE: To evaluate in infertile women the benefit of laparoscopic surgical treatment of endometriosis. PATIENTS AND METHODS: All infertile patients aged 18 to 43 years old, operated between February 2004 and March 2008, with a minimal follow-up of 18 months, coming from the Auvergne cohort of endometriosis has been, were included. The primary end point was the achievement of a pregnancy. RESULTS: One hundred and twenty-three patients have been included. Global pregnancy rate was 48%, which 47% was spontaneous with a mean postoperative delay of 6±4.5 months. Sixty-three patients had benefited from Assisted Reproductive Technology (ART) and 25 pregnancies were obtained (pregnancy rate: 39.7% with a mean delay of 10±3.8 months). Eighty-one percent of spontaneous pregnancies were obtained during the first 12 postoperative months. Duration of preoperative infertility and tubal involvement were significantly associated with lower spontaneous pregnancy rate. No significant differences were found between endometriosis stage I and II compared to stage III and IV, and between patient under 34 years old compared to older. DISCUSSION AND CONCLUSION: With this first study on infertility from the Auvergne cohort of endometriosis, we are confirmed that surgery is one of the central issues in the treatment of infertile endometriosis patient. The postoperative delay to obtain a spontaneous pregnancy requires a quick management by ART after 6 to 12 postoperative month and an immediate management by ART in case of tubal involvement or former infertility.

[Postoperative pain after transvaginal repair of pelvic organ prolapse with or without mesh]. / Douleurs postopératoires après cure de prolapsus génital par voie vaginale avec ou sans renfort prothétique.

OBJECTIVE: To assess postoperative pain after POP surgery by vaginal approach with and without mesh. PATIENTS AND METHODS: One hundred and thirty-two consecutives patients operated on for POP (POP-Q ≥ 2) were enrolled. Surgical procedure was a traditional repair without mesh in 66 women and a mesh repair (Prolift) in 66 women. Postoperative pain was prospectively assessed by autoadministred questionnaires including analog visual scale. Pain scores were recorded 1 day after surgery (D1), at discharge, at 1 month follow-up (M1) and at 3 to 6 months follow-up (M3-6). We focused specially on mesh repair, age, previous prolapse procedure, hysterectomy, sacrospinofixation, transobturator sling, pre- and postoperative POP-Q score. RESULTS: At discharge, pain score was significantly higher in the mesh group (1.2 ± 1.8 versus 0.5 ± 0.9, P=0.021). Pain score were low (VAS<3) and similar in the two groups with or without mesh at M1 and M3-6 follow-up. When focusing on associated factors, hysterectomy as a significant higher pain score at day 1, transobturator slings associated to traditional repair are more painful at D1 versus associated to mesh repair, sacrospinofixation has only a statistical tendency (P=0.08) more painful at D1. DISCUSSION AND CONCLUSION: Pain score are low after both traditional or mesh repair by vaginal route. Mesh repair, hysterectomy and sacrospinofixation are more painful only in the first days after surgery. Our study supports the theory that transvaginal mesh procedure allows a quick return to normal life.

Comparison of dysplasia profiles in stimulated ovaries and in those with a genetic risk for ovarian cancer.

AIM: Ovarian epithelial dysplasia (OED) was first described after prophylactic oophorectomy for genetic risk of ovarian cancer. In light of Fathalla's incessant ovulation theory, this study was set up to describe the presence of ovarian abnormalities (dysplasia) after ovulation induction and to compare dysplasia profiles in stimulated and genetic risk ovaries. METHODS: One-hundred and twenty-four patients who had undergone salpingo-oophorectomies or ovarian cystectomies between 1990 and 2005 were reviewed. They were divided into three groups: (1) previous in vitro fertilisation (n=35); (2) prophylactic oophorectomies for genetic risk (n=27) and (3) fertile non-cancerous controls (n=62). Eleven cytological and architectural epithelial features were defined and a dysplasia score was calculated to quantify ovarian epithelial abnormalities. RESULTS: Mean dysplasia score was significantly higher in the genetic risk and stimulated ovary groups than in controls (9.55 versus 3.62, p<0.0001; 7.51 versus 3.62, p<0.0002, respectively). Cytological and architectural abnormalities were more frequent in the genetic risk group, while the profile of abnormalities was different in the genetic risk and stimulated groups. CONCLUSIONS: These findings support a possible relationship between OED and the use of ovulation-stimulating drugs. The increased dysplasia score in stimulated and genetic risk ovaries might be consistent with progression towards neoplastic transformation, and may justify the use of the term dysplasia or intraepithelial ovarian neoplasia. The observation of dysplasia in the stimulated group may differentiate women at risk. Conversely, the fact that the dysplasia profile after stimulation differs from that in genetic risk ovaries suggests that ovarian stimulation may predispose to a different evolution.

Ovarian epithelial dysplasia after ovulation induction: time and dose effects.

BACKGROUND: Ovarian epithelial dysplasia was first described after prophylactic oophorectomies for genetic risk. Ovarian stimulation has been considered as a risk factor of ovarian cancer by Fathalla's incessant ovulation theory. In this study, we have investigated the risk of ovarian dysplasia after ovulation induction. METHODS: We reviewed 99 oophorectomies or cystectomies between 1990 and 2005 divided them into two groups: previous in vitro fertilization (n = 37) and a panel of fertile controls (n = 62). Eleven epithelial cytological and architectural features were defined and an ovarian epithelial dysplasia score was calculated to quantify the degree of ovarian epithelial abnormalities. RESULTS: All the ovaries were macroscopically non-cancerous except in two patients (one endometrioid cancer and one borderline tumour). The mean ovarian dysplasia score was significantly higher in the ovulation induction group than in the control group (7.64 versus 3.62, P = 0.0002). We also found a relationship between the number of ovulation-inducted cycles and the severity of ovarian dysplasia ('dose-effect') and a relationship between time after the end of ovulation induction (over 7 years) and the severity of ovarian dysplasia ('time-effect'). CONCLUSIONS: There is probably a relationship between ovarian epithelial dysplasia and either ovulation inducing drugs or infertility. By Fathalla's incessant ovulation theory, 'the dose effect and the time effect' of ovarian stimulation may explain ovarian dysplasia formation.

[Ovarian epithelial dysplasia: myth or reality? Review]. / Dysplasie épithéliale ovarienne: mythe ou réalité? Revue de la littérature.

Ovarian epithelial dysplasia has been described in the ovarian surface epithelium by histologic, morphometric and nuclear profile studies. It could represent a potential precursor of ovarian malignancy in patients with genetic risk of ovarian cancer, although its natural history and progression to carcinoma are unpredictable. Diagnosis and identification of ovarian dysplasia would certainly be useful to understand the early steps of ovarian carcinogenesis. However, dysplasia in relation with ovulation induction seems to have a different pattern. We report dysplasia definitions and the current clinical management.

[Are there anatomical and clinical correlations between minimal and deep endometriosis? First results of Auvergne's Registry of Endometriosis]. / Existe-t-il une corrélation anatomoclinique entre endométriose minime et endométriose sévère? Premiers résultats du registre régional d'Auvergne de l'endométriose.

OBJECTIVE: With a prospective study, to evaluate the existence of two distinct clinical diseases in the endometriosis syndrome, by comparing pain symptoms and quality of life from patients with minimal endometriosis (AFS-R<5) and data from patients with severe disease (deep infiltrating nodules and/or ovarian endometrioma). PATIENTS AND METHODS: Patients with minimal disease (group A with AFS-R<5) and severe endometriosis (group B) are selected from the Auvergne Endometriosis Registry which started in January 2004. They have never been treated before for endometriosis. A surgical laparoscopic and a pathological diagnosis are required for the subjects to be included. Pelvic pain is assessed using a standardized questionnaire, and a visual analogue scale, quality of life using SF-36. The two groups are compared for the incidence and the severity of pelvic pain and for the impairment of their quality of life. RESULTS: Forty-seven patients have a minimal disease, whereas 111 have a severe endometriosis. Demographic characteristics are similar in both groups. Quality of life (SF-36) and pelvic pains included chronic pelvic pain, dyspareunia, dysuria, and defecation disorders are as common and severe in both groups. However, dysmenorrhea is more affected in group B than in group A (p=0.03). DISCUSSION AND CONCLUSION: We find no relationship between severity of symptoms, quality of life, and the extent of endometriotic lesions at surgery. There would be no differences between minimal and severe disease. It could be explained by different painful mechanisms between minimal and severe endometriosis.

[Profiles of people who return unused medicine to pharmacies in Puy-de-Dôme, and their motivations for doing so]. / Profils et motivations des personnes déposant des Médicaments Non Utilisés (MNU) dans les officines du Puy-de-Dôme (France).

An unused drug (U.D.) is described as a drug which is purchased, whether according to a prescription or not, but which is not taken. In the past few years, French people have acquired the habit of returning U.D.s to pharmacies. Nevertheless, few studies have been performed to define their typical features and the motivations of these individuals. A descriptive study was carried out in 1/5 of the pharmacies in Puy de Dôme (France) over three 1 week periods between February and June 1998. 377 people (that is, 82% of those who bring U.D. back to the pharmacies) accepted to participate in this study. The main results are as follows: 1. the U.D. are primarily brought back by women (of all ages); 2. these women mainly return U.D. from the family medicine cabinet; 3. the donations result essentially from "the force of habit", "cleaning out the family medicine cabinet" and also, although in lesser proportion, for "humanitarian reasons". This behaviour is contradictory with the communication messages of Cyclamed, the official French association whose mission is to collect drug waste and unused drugs in order to preserve the environment and to promote energy development and valorisation.

[Description of unused drugs collected in pharmacies in the Puy-de-Dôme region in France]. / Description des Médicaments Non Utilisés (MNU) collectés dans les pharmacies du Puy-de-Dôme.

BACKGROUND: An unused drug (UD) is defined as a drug which is purchased, after prescription or not, but which is not taken. Public health campaigns in France have requested people to return these drugs to their pharmacy. To data, few data have been available concerning the quantity of collected UD and their potential re-use. A study was performed in the pharmacies of the Puy-de-Dôme region in France to describe the UD circuit. METHODS: A random sample of 1 out of 5 pharmacies in the Puy-de-Dôme region (France) were defined by single level stratified sampling from the list of all pharmacies operating in the region. An exhaustive record of all UD people brought back to these pharmacies was made in 1998 during three 1-week periods. The following data were recorded for each UD: the name of the drug, the pharmaceutical industry code (CIP), the price, the rate of social Security refunding, the mention of "free specimen" on the package, the inscription on the list of poisonous substances and on the list of essential drugs defined by the World Health Organization (WHO), the registration on the list of drugs reserved for hospital use, the packaging notice (opened or not), the therapeutic class, and the formulation. RESULTS: 10,254 US (717kg) were collected during the study period. The therapeutic classes of the UD were similar to those of drugs purchased in France. According to the selling price, these UD had an economic value of 405,845FF (i.e. 3.6% of Social Security refundings paid in the Puy-de-Dôme region during this same period). Only 20% of the UD were potentially reusable for humanitarian purposes. Their estimated economic value was 87,456FF (i.e. 0.78% of the annual Puy-de-Dôme Social Security refunding). Moreover, 43.4% of the reusable drugs were on the WHO list of essential drugs. CONCLUSION: Although the volume of collected UD is high, use by humanitarian associations is on the decline because of the cost of collection and low economic yield. Furthermore, UD must be collected in a systematic manner to preserve the environment and prevent domestic accidents.