Classification Of Endometriosis Research Articles

Right endometrioma is related with more extensive obliteration of the Douglas pouch

To investigate that endometrioma is an asymmetric disease with left lateral predisposition as compared to other benign ovarian cyst and also, whether endometrioma side is related with endometriosis severity. Operative and histopathologic findings of 340 women who underwent cystectomy for treatment of endometriotic (n = 239) and nonendometriotic ovarian cysts (n = 101) by laparoscopy (n = 268) or laparotomy (n = 72) between January 2005 and August 2009 were evaluated retrospectively. We compared left and right sided distribution of endometriotic and nonendometriotic ovarian cysts, and we also investigated the extent of endometriotic foci, obliteration of pouch of Douglas and endometriosis stage according to the revised American Fertility Society classification of endometriosis to assess whether endometrioma side is related with the severity of endometriosis. Of 239 women with endometriosis, endometrioma was found in the left ovary (n = 109), right ovary (n = 58) and bilaterally (n = 72). Of 101 control group women functional and dermoid cysts were found in the left ovary (n = 48), right ovary (n = 43) and bilaterally (n = 10). Among women with unilateral ovarian endometrioma (n = 167) a left cyst (63.3%) was found more frequently than a right cyst (34.7%) (P < 0.0001). In women with a left ovarian endometrioma pouch of Douglas was open in 99 (90.8%) cases. However, it was partially obliterated in 3 (2.8%) and completely obliterated in 7 (6.4%) cases. On the other hand, in women with a right endometrioma it was open in 44 (75.9%) cases and partially obliterated in 2 (3.4%) and completely obliterated in 12 (20.7%) cases. In women with a right endometrioma, the possibility of the pouch of Douglas obliteration is significantly higher than the women with a left endometrioma (P = 0.006). Moreover, we also showed that in women with a right endometrioma, incidence of the pouch of Douglas obliteration is higher and the endometriosis tends to be more severe compared to women with a left endometrioma. Our most relevant observation is obliteration of Douglas pouch which was found to be more extensive in women with right ovarian endometrioma. Our results showing left lateral predisposition of endometriomas are in agreement with the previous reports and highlight the retrograde menstruation theory for the pathogenesis of this enigmatic disorder.

Vaginal danazol for the treatment of endometriosis-related pelvic pain

doi:10.1016/j.ijgo.2011.07.033 menstrual flow was moderate, endometriosis was minimal; when menstrual flow was heavy, endometriosis was severe. In conclusion, the characteristics of infertile Maltese women diagnosed with endometriosis are similar to those reported in the literature [1,3,4]. A relationship between the amount of menstrual flow and the classification of endometriosis was observed. In general, treatment strategies involve patients with minimal endometriosis receiving no treatment, or GnRH agonist treatment across the spectrum of endometriosis.

Endometriosis classification

Endometriosis remains an enigmatic disease for many reasons, not the least being a continued inability to stage its clinical presentation so that prognosis and treatment for both pain and infertility patients can be facilitated. This article reviews issues with current staging systems. The revised American Fertility Society (rAFS) classification system has historically been the only classification system. Recently, the ENZIAN classification system, developed as an adjunct to the rAFS to describe more severe disease, has been introduced but is rarely used. More recently, the Endometriosis Fertility Index (EFI) that has been validated to predict pregnancy rates in infertility patients following surgical diagnosis and treatment of endometriosis was published. Currently, the AAGL is developing a categorization system that will be more focused on pain. Novel research in imaging, biomarkers, histology, and the human genome may provide useful information to develop future classification systems. The only validated endometriosis classification system that predicts a clinical outcome is the EFI. It is to be hoped that renewed interest in the importance and utility of classification systems will result in novel classification systems that are clinically useful.

Identification of Cells with Colony-Forming Activity, Self-Renewal Capacity, and Multipotency in Ovarian Endometriosis

Endometriosis, the growth of endometrial tissue outside the uterine cavity, is a common gynecological disorder affecting 10% to 15% of women in their reproductive years. Retrograde menstrual shedding containing endometrial stem/progenitor cells has been postulated to be involved in its pathogenesis. In this study, we identified putative endometriotic stem/progenitor cells by their colony-forming potential, self-renewal capacity, and multipotency. Purified epithelial and stromal cells isolated from ovarian endometriotic cysts formed large and small colony-forming units (CFUs) in clonogenic assay. The colony-forming activity of epithelial and stromal cells was found to differ greatly between autologous endometrium and ovarian endometrioma samples. The large CFUs could propagate more than the small CFUs. The endometriotic epithelial small CFUs expressed epithelial markers (epithelial cell adhesion molecule, cytokeratin, and α6 integrin); only occasional large CFUs expressed α6 integrin. Aside from the expression of fibroblast markers, stromal CFUs also expressed three somatic stem cell markers: sal-like 4, CD133, and Musashi-1. Endometriotic stromal cells derived from large CFUs could differentiate into four mesenchymal lineages when cultured in the respective inducing-media, as determined by histochemical staining and RT-PCR of lineage specific markers. These findings demonstrate that ovarian endometrioma contains a subset of cells displaying somatic stem cell properties.

Sa1440 EUS/Trus-FNA for Preoperative Histological Diagnosis of Deep Intestinal Endometriosis

Intestinal endometriosis (EDT) is frequently an oligo or asymptomatic disease. MRI, transvaginal ultrasound and intestinal endosonography play significant role to determine endometriosis's depth of invasion along intestinal wall. Histological diagnosis depends on the analysis of surgical specimens. Patient not indicated for surgery are treated without histological confirmation. Nevertheless, a differential diagnosis of a malignant disease can be missed. Histological diagnosis through EUS/TRUS-FNA can confirm endometriosis diagnosis, and its differentiation, helping the treatment decision. We described the technical use of two different models os 22g needle: using a conventional EUS equipment and EUSN (Cook Incorporeted) and a rigid linear probe (Hitachi) with Chiba needle. EDT intestinal commitment was classified according Echo-Logic Classification for endometriosis, that uses T for deep of infiltration and L for localization of the EDT nodule, as follows: ueT1: no intestinal commitment; ueT2: affecting the serosa/adventitia; ueT3: affecting muscularis propria; ueT4: affecting submucosa; ueT5: affecgting mucosa; L1: retrovesical; L2 paracervical; L3: retrocervical; L4: peritoneal reflection; L5 retovaginal septum. We performed 38 EUS-FNA (EUSN 22g needle) and 59 TRUS-FNA (Chiba 22g needle) in 97 women with rectum or sigmoid deep endometriosis. All of them had disease affecting, at least, serosa/adventitia and muscularis propria. 52 patients of them were submitted to surgical ressection. The results of FNA material and surgical ressection were compared. The medium age was 34,9 years (24 - 58). The most frequent localization was ueT4 (submucosa) and L3 (retrocervical). Among the 97 patients, we were able to obtain histological diagnosis of intestinal endometriosis in 95 (97,9%). There was no difference between EUS and TRUS FNA methods. All of ressected patients confirmed intestinal endometriosis on pathological specimens. There was 1 complication (anal fissure). EUS/TRUS-FNA is an effective method to make preoperative histologic diagnosis of deep intestinal endometriosis.

T helper (Th)1, Th2, and Th17 interleukin pathways in infertile patients with minimal/mild endometriosis

In the present study, interleukin (IL)-10, IL-12, IL-17, and IL-23 levels were measured in serum and peritoneal fluid of women with minimal or mild endometriosis and compared with levels in controls without endometriosis. Higher IL-23 levels were encountered in the peritoneal fluid of women with endometriosis, suggesting a possible role of this cytokine in these women's infertility.

Ultrasonographic staging: a new staging system for deep endometriosis

Modern imaging techniques allow for the noninvasive diagnosis of endometriosis. Preoperative staging of pelvic endometriosis helps the gynecologist plan therapy and offer a prognosis to patients. The challenge of creating a satisfactory classification of endometriosis remains. The ability of the current classification schemes to predict pregnancy outcome, or aid in the management of pelvic pain, is recognized to be inadequate. The study of deeply infiltrating endometriosis and adenomyosis is greatly hampered by a lack of clear terminology and the absence of a consensus classification of the lesions. A reviewed consensus classification of endometriosis in general, with a more detailed consideration on deep endometriosis, is urgently required. We suggest a new staging system for deep, infiltrating endometriosis based on ultrasonographic findings. Prospective data collection and review in large centers may provide a larger clinical base from which to derive empirical point scores and breakpoints in the classification scheme.

Decreased concentrations of pigment epithelium–derived factor in peritoneal fluid of patients with endometriosis

To determine whether patients with endometriosis have altered levels of pigment epithelium-derived factor (PEDF) in peritoneal fluid, concentrations of PEDF in peritoneal fluid collected from 42 patients with endometriosis and 30 patients without endometriosis were measured with enzyme-linked immunosorbent assay. We detected significantly lower levels of peritoneal fluid PEDF in patients with endometriosis compared with patients without endometriosis, suggesting that peritoneal fluid PEDF plays a role in the pathogenesis of this disorder.

Overexpression of nerve growth factor in peritoneal fluid from women with endometriosis may promote neurite outgrowth in endometriotic lesions

To investigate the role of the nerve growth factor (NGF) in the endometriosis-associated innervation in the development of endometriosis-associated symptoms, 41 peritoneal fluid samples (PF) from patients with surgically and histologically proven endometriosis and 20 PF from patients with other gynecologic conditions were analyzed with Western blot and a novel in vitro model using dorsal root ganglia (DRG) to show neuronal outgrowth; endometrial cells also were analyzed. The results suggest that the PF of endometriosis patients and endometriotic lesions have neurotropic properties, because the Western blot analysis and the cell culture stainings showed NGF expression, and the neurite outgrowth of DRG treated with PF of patients with endometriosis was significantly higher than when treated with PF of patients without endometriosis. Furthermore, blocking NGF with both anti-NGF and K252a leads to a significant decrease in neurite outgrowth.

CA 125 serum values in surgically treated endometriosis patients and its relationships with anatomic sites of endometriosis and pregnancy rate

Endometriosis is a benign gynecologic disease defined as the presence of functional endometrial glands and stroma outside the uterine cavity, causing dysmenorrhea, dyspareunia, menstrual irregularities, and infertility. Serum CA-125 measurement is now a consolidated method for diagnosing this condition, and its interpretation has posed a number of problems, particularly regarding utility in diagnosing minimal-mild endometriosis, whereas its value as a diagnostic aid in moderate-severe stages is well recognized. In our cohort, serum CA-125 values were significantly elevated in patients with ovarian and mixed endometriosis lesions (median levels 48 U/mL), compared with those who had exclusively extraovarian foci (median levels 27 U/mL), and so the correlation between this marker and the surgical and pathologic finding of ovarian and deep endometriosis was found to be statistically significant; however, the location did not affect the fertility rate.

An endometriosis classification, designed to be validated

Several endometriosis classifications were proposed, based on the assumption that endometriosis is a progressive disease, and designed to score severity of visible lesions. In addition, several specific classifications, e.g., for deep endometriosis, were proposed. None of these classifications however, have been validated to be predictive for diagnosis, treatment prognosis, recurrence, progression or for the associated infertility or pain. The difficulties derive from the fact that pathophysiology and the natural history are still uncertain. A classification should avoid assumptions. It seems established beyond reasonable doubt that endometriosis presents as subtle, typical, cystic, and deep lesions and that severity of each lesion is related to size or volume. By pathology, these four lesions present as active, burnt-out, inactive, and active lesions, respectively. Besides this, there are many uncertainties. It is unclear whether endometriosis is one disease progressing ultimately into severe endometriosis or whether typical, cystic, and deep endometriosis represents three different diseases, each being an end stage. It is unclear whether endometriotic cells are different from endometrial cells or whether only the environment is different. It is unclear how adenomyosis, Müllerianosis, and peritoneal pockets should be considered. We therefore suggest a descriptive classification with the severity of Subtle, Typical, Cystic, Deep, Adenomyotic, and peritoneal pocket lesions, estimated by their area or volume. This classification should permit to evaluate the actual uncertainties in order to build subsequently a validated classification. The similarity of the classes for superficial and cystic lesions with the rAFS classification is considered an advantage. It is discussed why adhesions need not to be scored. In conclusion, a simple classification scoring separately severity of subtle, typical, cystic, deep, adenomyotic, and peritoneal pocket lesions is suggested. This will permit to confirm or reject statistically many of the actual uncertainties on endometriosis and to evaluate what the predictive power of the severity of each type of lesion is, both essential elements for a validated endometriosis classification.

Aberrant expression of the pluripotency marker SOX-2 in endometriosis

Expression of the pluripotency factors SOX-2, OCT-4, KLF-4, and NANOG was analyzed by quantitative real-time polymerase chain reaction, immunohistochemistry, and immunofluorescence microscopy in the endometrium, myometrium, and endometriotic tissue of 36 patients. Aberrant expression of SOX-2 may indicate a stem cell origin of endometriosis, whereas the presence of all progenitor markers in endometrial tissue marks the endometrium as a potential source for induced pluripotent stem cell generation.

Increased plasma levels of phthalate esters in women with advanced-stage endometriosis: a prospective case-control study

We performed the present prospective case-control study to evaluate whether the plasma concentrations of phthalate esters are elevated in women with advanced-stage endometriosis in a Korean population. Measuring plasma levels of monoethylhexyl phthalate and di-(2-ethylhexyl) phthalate in 97 women with advanced-stage endometriosis and 169 control women by liquid chromatography-tandem mass spectrometry, we found that the concentrations of monoethylhexyl phthalate, as well as di-(2-ethylhexyl) phthalate, are significantly higher in those with advanced-stage endometriosis, which supports the hypothesis that exposure to phthalate might play a role in the establishment of endometriosis.

Matrix metalloproteinases are elevated in the urine of patients with endometriosis

In a prospective, blinded, longitudinal study MMP-2, MMP-9, and MMP-9/neutrophil gelatinase-associated lipocalin were significantly more likely to be detected in the urine of patients with endometriosis than in controls.

The classification of endometriosis. A literature overview and a proposal for a new classification system for endometriosis and infertility

Endometriosis is responsible for major morbidity in women of childbearing age. Although there is reasonable evidence confirming an association between endometriosis and infertility, a causal relationship has not yet been established. Endometriosis is also responsible for impairment of quality of life, which may be present from menarche to the fourth decade, and sometimes even in menopausal years. Although we do not yet fully understand the underlying pathophysiology, more and more evidence is arising as this being multifactorial in origin with possible genetic susceptibility. Patients need effective, safe treatment and if possible cure of their disease state, with restoration of fertility if impaired and delivery from the everyday clinical symptoms associated with active disease. Clinicians need accurate screening tools for disease, with high specificity, diagnostic tests to confirm suspected disease, and ultimately treatment modalities to offer their patients. Severity of disease usually correlates with degree of impairment of function. Severity or stage is usually based on degree of organ involvement, whether being functional or anatomical. A staging system should be based on the natural history of the disease, its local invasiveness, and its functional as well as organic consequences.

Patients' report on how endometriosis affects health, work, and daily life

The objective of this study was to assess the burden of endometriosis by obtaining patient-reported outcome data describing the experience of living with this disease. Survey data from 107 women with self-reported, surgically diagnosed endometriosis showed that living with this disease may be characterized by physical limitations that disrupt health, work, and daily life.

Study on transvaginal hydrolaparoscopic pelvic adhesiolysis in the infertile women

To investigate the safety and efficacy of transvaginal hydrolaparoscopic pelvic adhesiolysis (THLPA) treatment in the infertile women. From May 2007 to Sep. 2008, 30 infertile patients underwent THLPA. The dye-test, hysteroscopy, and dye-test using catheterization of tubal ostium by hysteroscopy were performed at the same time. Pelvic adhesions were scored according to the revised American Fertility Society classification of endometriosis (1985). The adhesions were graded as mild (score 1-9), moderate (10-19), and severe (>/= 20). Twenty-four cases were in mild adhesions, 5 moderate adhesions, and 1 severe adhesion. The duration of the operation and discharge, pelvic adhesions score, tubal patency, complications, and pregnancy rate were investigated. (1) THPLA: the majority of pelvic adhesions in all patients were successfully performed adhesiolysis. Only a little filmy adhesions of proximal peritube of 7 tubes and proper ligament of 5 ovaries and cohesive adhesions of 4 ovaries did not underwent surgical lysis. (2) Tubal patency: 35 tubes were of proximal occlusion by dye-test, of which 21 (60%, 21/35) were unobstructed and 4 (11%, 4/35) were partly unobstructed after the dye-test using catheterization of the tubal ostium by hysteroscopy. (3) The duration of operation: the overall operative time were (32 +/- 6) minutes in mild adhesion, (52 +/- 6) minutes in moderate adhesion, and 83 minutes in severe adhesion. Of which the time of THLPA were (11 +/- 5) minutes in mild adhesion, (35 +/- 7) minutes in moderate adhesion, and 62 minutes in severe adhesion, respectively. (4) The duration of discharge: the postoperative discharge time was 120 - 175 minutes. No complications occurred. (5) The rate of pregnancy: in the (15.8 +/- 4.3) months' follow-up, the rate of pregnancy was 45% (13/29), which one patient lost follow-up. THLPA is safe, efficacious and not being hospitalized management. When compared with laparoscopy, it is simpler, more economic, and less minimally invasive approach. The appropriate indication of THLPA is to treat filmy, especially mild pelvic adhesions. It could partly avoid transabdominal operative laparoscopy for the infertile women.

Comparison of the clinical value of CA 19-9 versus CA 125 for the diagnosis of endometriosis

Preoperative blood samples and intraoperative tissue specimens were obtained from 101 patients with endometriosis and 78 patients without endometriosis referred for benign gynecologic operations to investigate the clinical value of serum and tissue CA 19-9 levels in the diagnostic evaluation of endometriosis as compared to CA 125. Our prospective cohort study showed that serum CA 19-9 is a valuable marker in the diagnosis of endometriosis, and it may be used to predict the patients with severe endometriosis when used with CA 125.

Negotiating science and experience in medical knowledge: Gynaecologists on endometriosis

This paper analyses the gynaecological literature on endometriosis, particularly endometriosis classification, to evaluate the epistemological concepts it uses. A qualitative content analysis was conducted on a sample of gynaecological literature published between 1985 and 2000, a period that witnessed the explosion of both evidence-based and patient-centred models of medicine, with their duelling emphases on science and experience. It was found that the discourse of science is used strategically in this literature as a formal epistemology to lend weight to authors' claims and to guide medical thinking and research. However, gynaecologists also use the notion of experience to assert their own credibility and to question the credibility of other experts. In fact, accounts of their own experience and the experiential accounts of their patients are foundational to gynaecologists' claims-making activities, including their engagement with scientific research.

Aromatase inhibitors prevent the estrogen rise associated with the flare effect of gonadotropins in patients treated with GnRH agonists

This was a preliminary study to determine the effect of aromatase inhibitors in preventing the flare induced by GnRH agonist (GnRH-a) in women with endometriosis (n = 9) or leiomyomata (n = 4) who were given letrozole on the first 5 days of the GnRH-a therapy. Serum LH and FSH levels showed the typical flare 1 day after the injection of the GnRH-a; however, E(2) declined immediately after letrozole administration and was notably suppressed at 1, 2, and 4 days after GnRH-a. No patients complained of clinical symptoms typical of the GnRH-a flare phenomenon.