Deep endometriosis conundrum: evidence in favor of a peritoneal origin.

OBJECTIVE: To determine whether the depth and volume of the pouch of Douglas differs in patients with endometriosis with and without deep lesions and to compare them with subjects with a healthy pelvis or with diseases other than endometriosis. DESIGN: Prospective, comparative study. SETTING: Tertiary care and referral center for patients with endometriosis. PATIENT(S): Women undergoing laparoscopy for infertility, pelvic pain, or adnexal anomalies (deep endometriotic rectovaginal lesions in 16 cases, endometriosis without deep lesions in 127 cases, miscellaneous anomalies in 35 cases, and normal pelvis in 26 cases). INTERVENTION(S): Douglas pouch depth measurement from the upper border of uterosacral ligaments to its base with a calibrated probe and volume assessment by a fluid-filling technique. MAIN OUTCOME MEASURE(S): Douglas pouch depth and volume. RESULT(S): Mean (+/-SD) Douglas pouch depth and volume measurements were 3.6 +/- 1.6 cm and 41.6 +/- 19.3 mL in women with deep endometriosis, 5.3 +/- 0.8 cm and 67.2 +/- 18.1 mL in those with peritoneal and ovarian lesions only, 5.2 +/- 0.9 cm and 67.6 +/- 12.6 mL in those with miscellaneous conditions, and 5.5 +/- 0.8 cm and 65.8 +/- 10.9 mL in those with normal pelvis. CONCLUSION(S): Reduced Douglas pouch depth and volume in women with deep endometriosis suggest that such lesions develop not in the rectovaginal septum but intraperitoneally and that burial by anterior rectal wall adhesions creates a false bottom, giving an erroneous impression of extraperitoneal origin.

A levonorgestrel-releasing intrauterine system for the treatment of dysmenorrhea associated with endometriosis: a pilot study.

OBJECTIVE: To evaluate the efficacy and safety of an intrauterine system releasing 20 microg of levonorgestrel per 24 hours in the long-term treatment of recurrent dysmenorrhea in women already operated on conservatively for endometriosis. DESIGN: A prospective noncomparative pilot study. SETTING: A tertiary care and referral academic center for patients with endometriosis. PATIENT(S): Twenty parous women with recurrent moderate or severe dysmenorrhea after conservative surgery for endometriosis who did not want further children. INTERVENTION(S): A levonorgestrel-releasing intrauterine system was inserted in each woman within 7 days of the start of a menstrual cycle. MAIN OUTCOME MEASURE(S): Variations in severity of dysmenorrhea during treatment according to a 100-mm visual analogue scale and a 0-3-point verbal rating scale, modification of a pictorial blood-loss assessment chart devised to evaluate the amount of menstrual flow, and degree of satisfaction after 12 months of therapy. RESULT(S): One woman was lost to follow-up after achieving amenorrhea and expressing satisfaction, and 1 requested system removal because of weight gain and abdominal bloating. In another subject, the levonorgestrel intrauterine system was expelled 3 months after insertion. The menstrual patterns in the remaining 17 women were characterized by amenorrhea in 4 cases, hypomenorrhea or spotting in 8, and normal flow in 5. Baseline and 12-month follow-up mean +/- SD blood loss scores were 111+/-36 and 27+/-26, respectively. At the same time, mean +/- SD visual analogue and verbal rating scale scores dropped, respectively, from 76+/-12 to 34+/-23 points and from 2.5+/-0.5 to 1.2+/-0.5 points. Four women were very satisfied with treatment, 11 were satisfied, 2 were uncertain, and 3 were dissatisfied at 12-month follow-up. CONCLUSION(S): Because of the amenorrhea or hypomenorrhea induced in most women, a levonorgestrel intrauterine system greatly reduced menstrual pain associated with endometriosis and achieved a high degree of patient satisfaction.

Menstrual characteristics in women with and without endometriosis.

OBJECTIVE: To assess menstrual blood loss and other menstrual characteristics prospectively in women with and without endometriosis. METHODS: Three hundred fifteen premenopausal women undergoing laparoscopy for various reasons were asked to complete a pictorial blood loss assessment chart devised by Higham et al to evaluate menstrual flow on which the monthly score has been demonstrated to correlate directly with uterine blood loss measured by the alkaline hematin method. In addition, cycle length and flow duration were recorded. The women also were asked to grade dysmenorrhea severity using a 100-mm visual analogue and a 0-3-points verbal rating scale. RESULTS: One hundred sixty-three women had endometriosis, and 152 did not. The latter group comprised 59 women with a normal pelvis, 36 with nonendometriotic ovarian cysts, 29 with chronic pelvic inflammatory disease, and 28 with miscellaneous conditions. The median [interquartile range] pictorial blood loss assessment chart score was 110 [66.5-156.5] in women with endometriosis and 84 [56-129] in those without the disease (P = .007); 87 out of 163 (53%) women with endometriosis had a menstrual chart score equal to or greater than 100 compared with 56 out of 152 (37%) of those without (chi 2(1) = 8.02, P = .005; difference = 16%, 95% confidence interval, 6%, 28%). Menstrual flow duration was slightly longer in women with endometriosis (mean difference, 0.33 days). Dysmenorrhea visual analogue and verbal rating scores were significantly higher in the endometriosis than the nonendometriosis group. CONCLUSION: According to a visual chart, women with endometriosis had heavier menstrual flow and a significantly higher rate of abnormal menstrual scores that those without the disease.

Risk factors for adenomyosis.

In order to analyse risk factors for adenomyosis, 707 consecutive women who underwent hysterectomy between January 1993 and June 1994 at the Clinica Luigi Mangiagalli, Milan, Italy, were interviewed before surgery by trained physicians. Information on the presence of adenomyosis was obtained from pathologic records. Out of the 707 women, adenomyosis was identified in 150 subjects (21.2%). Women who smoked tended to be at decreased risk of the condition: in comparison with women who had never smoked, the risk for current smokers was 0.7 (0.3-1.3) and the risk decreased with number of cigarettes smoked per day, the odds ratios being 0.8 and 0.6 respectively in women reporting fewer than 10 and more than 10 cigarette smoked per day (chi2 trend 3.57, P = 0.06). The frequency of adenomyosis was higher in parous women: in comparison with nulliparae, the odds ratio of the disease were 1.8 [95% confidence interval (CI) 0.9-3.4] and 3.1 (95% CI 1.7-5.5) respectively in women reporting one and two or more births (chi2 trend 20.71, P < 0.01). Likewise, women reporting one or more spontaneous abortions had an odds ratio of 1.7 (95% CI 1.1-2.6) for adenomyosis, in comparison with those reporting no spontaneous abortion.

Depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol for long-term treatment of pelvic pain associated with endometriosis.

OBJECTIVE: Our purpose was to evaluate the efficacy and safety of depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol in the long-term treatment of pelvic pain in women with endometriosis. STUDY DESIGN: Eighty patients with endometriosis and moderate or severe pelvic pain were randomized to treatment for 1 year with intramuscular depot medroxyprogesterone acetate 150 mg every 3 months or a cyclic monophasic oral contraceptive (ethinyl estradiol 0.02 mg, desogestrel 0.15 mg) combined with oral danazol 50 mg a day for 21 days of each 28-day cycle. The women were asked to grade the degree of their satisfaction at the end of therapy. Variations in severity of symptoms during treatment were determined by a 10 cm visual analog and a 0- to 3-point verbal rating scale. RESULTS: Twenty nine of 40 subjects (72.5%) in the depot medroxyprogesterone acetate group were satisfied after 1 year of therapy compared with 23 of 40 (57.5%) in the oral contraceptive plus danazol group (chi 2(1) = 1.37, p = 0.24, odds ratio 1.95, 95% confidence interval 0.76 to 4.97). A significant decrease was observed in all symptom scores in both study groups. At 1-year assessment dysmenorrhea was significantly greater in women allocated to oral contraceptive plus danazol. CONCLUSION: Depot medroxyprogesterone acetate seems to be an effective, safe, and convenient low-cost treatment for pelvic pain associated with endometriosis. However, women should be carefully counseled regarding menstrual changes and the potential prolonged delay in the return of ovulation.

PIP: The tolerability and effectiveness of depot medroxyprogesterone acetate (DMPA), compared with an oral contraceptive (OC) combined with low-dose danazol, in the long-term treatment of pelvic pain in women with endometriosis were evaluated in a randomized clinical trial. 40 women were allocated to each treatment regimen. At the 1-year assessment, a significant decrease was observed in all symptom scores of the visual analog and the verbal rating scale in both study groups. Only pain at menstruation was significantly greater in women in the OC group (because of the absence of regular flow in subjects in the DMPA group). In the DMPA group, 1 woman (2.5%) was very satisfied with her treatment, 28 (70%) were satisfied, 2 (5%) were uncertain, and 1 (2.5%) was very dissatisfied. Corresponding figures for the OC-danazol group were 6 (15%), 17 (42.5%), 4 (10%), 12 (30%), and 1 (2.5%). Overall, 72.5% of women in the DMPA group compared with 57.5% of those in the OC group were pleased after 1 year of treatment. It was concluded that, in selected women with highly symptomatic endometriosis, DMPA offers good analgesic results with tolerable side effects.

Laparoscopic uterine biopsy for diagnosing diffuse adenomyosis.

OBJECTIVE: To investigate the possibility of diagnosing diffuse adenomyosis with the uterus in situ. STUDY DESIGN: Myometrial needle biopsy was performed on a prospectively evaluated series of 72 women undergoing laparoscopy for infertility and/or chronic pelvic pain. Before surgery the patients completed a questionnaire on the presence and severity of dysmenorrhea according to a linear analog and verbal rating scale. A single specimen was taken from along the median line in the upper third of the posterior uterine wall using a 14-gauge Tru-cut needle inserted through the anterior abdominal wall under laparoscopic guidance. RESULTS: No complications occurred. Adenomyosis was diagnosed in 8 of the 42 subjects with menstrual pain and 5 of the 30 asymptomatic ones (19% versus 17%) and pelvic endometriosis in 27 and 10, respectively (64% versus 33%, P = .02). The frequency of moderate or severe dysmenorrhea was greater in women with adenomyosis than in those without adenomyosis or endometriosis, but the difference was not statistically significant. Conversely, menstrual pain was significantly more frequent and severe in patients with endometriosis as compared with women who had neither endometriosis nor adenomyosis. CONCLUSION: Uterine needle biopsy is simple, rapid and safe, but its overall clinical importance, as well as the predictive value of a normal histologic result, requires further investigation.

Bladder detrusor endometriosis: clinical and pathogenetic implications.

PURPOSE: We examined the pathogenesis of vesical endometriosis, identified the diagnostic signs and defined a successful management strategy. MATERIALS AND METHODS: The records of 8 patients with bladder detrusor endometriosis were reviewed. RESULTS: Two distinct forms of the condition appear to exist, that is spontaneous and post-cesarean. In the former case the bladder lesion is a manifestation of a generalized pelvic disease, whereas after iatrogenic dissemination growth of ectopic endometrium is usually limited to the bladder wall. The catamenial nature of bladder symptoms (frequency, urgency, dysuria and tenesmus) was pathognomonic. Cystoscopy with biopsy was diagnostic in 3 cases. Ultrasonography revealed an endo-luminal vegetation and ruled out an anterior uterine leiomyoma, whereas magnetic resonance imaging did not add relevant information. Partial cystectomy appears to cure the urinary disturbances. CONCLUSIONS: We suggest a high index of suspicion of vesical endometriosis in all premenopausal women complaining of catamenial bladder symptoms with negative urine cultures.

Adenomyosis at hysterectomy: a study on frequency distribution and patient characteristics.

To evaluate the prevalence and risk factors for adenomyosis, the clinical records of consecutive women undergoing hysterectomy during a 3 year period were retrieved. Data were collected on indication for the intervention, general sociodemographic characteristics of the patients, age at menarche, parity, abortions, and menopausal status at surgery. Adenomyosis was diagnosed in 332 of the 1334 cases (24.9%). The condition was present in 146 of the 627 patients (23.3%) with fibroids and menorrhagia, 68 of the 265 (25.7%) with prolapse, 21 of the 98 (21.4%) with ovarian cysts, 19 of the 100 (19%) with cervical cancer, 31 of the 110 (28.2%) with endometrial cancer, 16 of the 57 (28.1%) with ovarian cancer, and 19 of the 77 (24.7%) with miscellaneous indications. These differences were not statistically significant (chi 2(6) = 11.14). In comparison with nulliparous women, the odds ratio was 1.3 and 1.5 respectively in women with one and > or = two births (chi 2(1) trend = 5.76 P < 0.05). No relationship was found between age at surgery, age at menarche, indications for surgery, menopausal status at intervention, and presence of endometriosis. Our findings do not support the notion that adenomyosis is more frequently related to particular clinical conditions, and suggest that parity may be associated with an increased frequency of adenomyosis.

Very low dose danazol for relief of endometriosis-associated pelvic pain: a pilot study.

OBJECTIVES: To evaluate the efficacy and safety of very low dose danazol in improving pelvic pain in women with endometriosis, the benefit of preceding the treatment by a short course of a GnRH agonist, symptoms recurrence after drug withdrawal, and variations in menstrual pattern. DESIGN: Open-label, randomized study. SETTING: University hospital endometriosis center. PATIENTS: Forty-two women with moderate or severe pelvic pain and laparoscopically diagnosed endometriosis. INTERVENTIONS: Treatment with oral danazol, 50 mg/d, for 9 months (group I, n = 21) or leuprolide depot for 3 months followed by oral danazol, 50 mg/d, for 6 months (group II, n = 21), and a 6-month follow-up. MAIN OUTCOME MEASURES: Variations in severity of symptoms during treatment and at the end of follow-up as shown by a linear analog scale and a verbal rating scale; menstrual blood loss as assessed by a pictorial chart. RESULTS: Four patients withdrew from the study, one in each group at the fifth month of treatment (for persistent pain) and one in each group during follow-up (they requested additional therapy); one woman in group I was lost to follow-up. Significant improvements were obtained in dysmenorrhea, deep dyspareunia, and nonmenstrual pain in both treatment schedules without differences between the groups. Also menstrual blood loss was significantly reduced in both groups. A temporary fall in high and rise in low density lipoprotein cholesterol was observed in the study population. At the end of follow-up symptoms recurred without significant differences in median pain scores with respect to baseline. CONCLUSION: Very low dose danazol may be an alternative for temporary relief of endometriosis-associated pain. Ovulation is not always inhibited and barrier contraception is needed. Side effects occur but are rarely severe. Further data are required to evaluate the influence of long-term administration on the lipid profile.

Gonadotropin releasing hormone agonist treatment before hysteroscopic endometrial resection.

OBJECTIVES: To evaluate the effects of treatment with the gonadotropin releasing hormone (GnRH) agonist goserelin before endometrial resection on absorption of distension medium fluid and technical feasibility of the surgical procedure. METHODS: Fifty-five patients reporting menorrhagia underwent endometrial resection after 2 months of goserelin depot therapy (33 cases) or during the proliferative phase of the cycle (22 controls). RESULTS: In the cases, the mean distension medium deficit +/- S.D. was 511 +/- 196 ml versus 647 +/- 245 ml in controls (P = 0.03), and the operating times were, respectively, 14 +/- 4 versus 18 +/- 5 min (P = 0.002). The intrauterine operating conditions were considered excellent or good in 64% of the cases versus 27% of the controls (chi 2 = 5.60, P = 0.02). CONCLUSIONS: GnRH agonists induce endometrial thinning, so that when administered before intrauterine interventions, mucus cellular debris and bleeding should be reduced during surgery and hysteroscopic visibility increased; the operating time may thus be shorter and fluid absorption decreased. However, more data are needed before considering GnRH agonists a proven effective means of facilitating endometrial resection.

A modified technique for correction of the complete septate uterus.

When correcting a complete uterine septum, it is recommended that one should spare the cervical portion to avoid the possible risk of cervical incompetence. However, it may be difficult to create a communication between the uterine cavities above the internal os. In seven patients with complete septate uterus we incised the cervical portion with Metzenbaum scissors and the corporal portion with microscissors under hysteroscopic guidance. The operating times were shorter and the distension fluid deficit smaller compared with nine historical controls in whom the cervical septum was spared. No intraoperative or obstetric complications were associated with cervical septal section. This modified technique is simple, rapid, safe, inexpensive, and may be considered among the alternative treatments to correct a complete septate uterus.

Adenomyosis: a déjà vu?

Adenomyosis is a relatively frequent finding in series of hysterectomies performed for menorrhagia and dysmenorrhea. Evident selection biases of the available studies on adenomyosis have always limited the possibilities of defining the real clinical importance of the condition. Until now the only certain diagnoses have been made by histopathologists on uteri removed at surgery, but recently various sufficiently accurate techniques have been suggested which allow diagnosis on the uterus in situ. With the these methods it might be possible to obtain correct information on the epidemiologic characteristics of adenomyosis and to clarify whether it has a pathogenic role in unexplained ovulatory menorrhagia and juvenile dysmenorrhea. Furthermore, resectoscopic treatment has been proposed in some mild forms of adenomyosis to avoid hysterectomy, whereas it seems improbable that medical treatment can offer a definitive solution. The adoption of standard histologic criteria for adenomyosis seems important. Until this is done, it will be difficult to establish whether adenomyosis is really a disease or merely a paraphysiologic condition.