Infiltrative Endometriosis Research Articles

12035 Robotic Resection of Deep Infiltrative Endometriosis of the Rectum and Vagina

12035 Robotic Resection of Deep Infiltrative Endometriosis of the Rectum and Vagina

Complications of deep infiltrative endometriosis of gastrointestinal tract

Objective. To summarize the literature data on the main complications of deep infiltrative endometriosis, including ileocecal. Endometriosis is a complex disease that can begin to develop from birth. Despite all the already existing theories of the origin and development of this disease, further large-scale studies are required to investigate the etiology, pathogenesis, and phenotypes of this nosology and its relationship with pain and infertility. External genital endometriosis often affects various parts of the gastrointestinal tract. The rectosigmoid junction of the colon is most commonly affected (81.3%), followed by the appendix (6.4%), small intestine (4.7%), dome of the cecum (4.1%), and other parts of the gastrointestinal tract (1.7%). In recent years, interest in ileocecal endometriosis and its timely diagnosis and treatment has begun to grow among practicing specialists. Presently, deep infiltrative endometriosis is widely studied by obstetricians–gynecologists and by related specialists, such as general surgeons, coloproctologists, and gastroenterologists, in connection with extragenital lesions leading to severe complications. Cases of intestinal perforation caused by deep infiltrative endometriosis, bleeding, and small intestinal obstruction have been described.

Douglas Pouch Fluid Improves the Accuracy of Transvaginal Ultrasound in the Diagnosis of Uterosacral Ligaments Deep Infiltration Endometriosis: A Prospective Study.

To compare the accuracy of transvaginal ultrasound (TVUS) with laparoscopy in detecting and characterizing uterosacral ligament (USL) nodules of deep infiltrative endometriosis (DIE) between patients with and without pouch of Douglas (POD) fluid. This prospective study was conducted between June 2021 and July 2023. We included patients from the Second People's Hospital of Shenzhen with two TVUS tests: no POD fluid on the first TVUS test and POD fluid on the second TVUS test. POD fluid was obtained in two ways: naturally occurring fluid during the luteal phase of the menstrual cycle and SonoPODography. Laparoscopic results are the gold standard. To compare the diagnostic performance of TVUS in the diagnosis of DIE on USLs with and without POD fluid. We included 42 patients with a mean age of 36.4 ± 5.4 years. The maximum length diameter for DIE nodules on USLs with and without POD fluid was 13.3 ± 3.3 mm and 10.2 ± 2.5 mm (P < .001), respectively, while the depth of infiltration was 8.1 ± 2.4 mm and 6.1 ± 1.4 mm (P < .001), respectively. When compared to laparoscopic findings, TVUS findings with and without POD fluid resulted in a sensitivity, specificity, accuracy, positive predictive value, negative predictive value area under the curve, and Cohen kappa of 92.3%, 93.8%, 92.9%, 96.0%, 88.2%, 0.930, and 0.850 and 61.5%, 93.8%, 73.8%, 94.1%, 50.0%, 0.766, and 0.499, respectively. Laparoscopy showed USL involvement in up to 59.5% of patients. With or without fluid, the most common ultrasound features of DIE lesions were USL thickening, irregular morphology, clear boundaries, low echo, and no blood flow signal. For patients with clinical suspicion of DIE, TVUS with POD fluid has a higher accuracy for diagnosing USL DIE than TVUS without POD fluid.

Clinical features of gastrointestinal symptoms in women with recurrent course of deep infiltrative endometriosis

Background. Endometriosis is a chronic multifactorial disease that affects more than 170 million women of reproductive age worldwide, causing pelvic pain syndrome, dyspareunia, and symptoms of gastrointestinal dyspepsia, thereby having a negative impact on the psycho-emotional state of patients. Despite a wide range of medical and surgical treatments, the relapse rate reaches 50%, which is a global economic and social problem.The purpose of the study. To determine the spectrum of clinical features of the gastrointestinal tract in women with recurrent deep infiltrative endometriosis.Materials and methods. The study included 113 patients of reproductive age who underwent surgical treatment of common forms of external genital endometriosis. The main group consisted of 32 patients who underwent repeated surgical treatment due to relapse of deep infiltrative endometriosis, the comparison group — 51 patients without relapse of the disease one year after the primary operation, the control group — 30 patients of reproductive age who did not suffer from external genital endometriosis. An analysis of the somatic anamnesis was carried out, as well as questionnaire data on pelvic pain on a visual analogue scale (VAS) and functional bowel disorders in patients with deep infiltrating endometriosis, depending on the status of relapse of the disease.Results and discussion. Patients of the main group suffered significantly more often from functional diseases of the gastrointestinal tract (71.9% (23/32) versus 51.3% (26/51) in the comparison group; p = 0.006, the spectrum of which was represented by chronic gastritis and irritable bowel syndrome. In the main group, the clinical manifestations of gastrointestinal dyspepsia before surgical treatment correspond to a moderately severe degree of 17.706 (4.601) points. A significantly higher initial level of functional intestinal disorders was established during subjective assessment in the main observation group: 17.706 (4.601) points versus 10.66 (3.61) points in the comparison group; p=0.001. In women of the main observation group, one month after surgical treatment, there was a significant decrease in subjective assessment of the severity of functional intestinal disorders (from 17.71 (4.60) points to 9.86 (4.73) points; p = 0.001). The integral VAS pain score in the main group was 6.65 (1.53) points, which is significantly higher than in patients in the comparison group without relapse of the disease.Conclusions. The identified clinical and anamnestic predictors of the recurrent course of deep infiltrative endometriosis will allow us to formulate a personalized approach at the pre- and postoperative stage, aimed at preventing relapse of the disease, which will directly improve the psycho-emotional state and quality of life of women.

Rare Broad Ligament Cavernous Hemangioma Mimicking Advanced Endometriosis: A Case Report.

Cavernous hemangioma within the female genital tract is an extremely rare pathology, characterized by irregular vascular spaces containing blood or thrombus. We present a unique case of a 42-year-old primiparous woman who presented with typical endometriosis symptoms such as dysmenorrhea, dyspareunia, and heavy menstrual bleeding. The patient also experienced complex postpartum symptoms, which were misdiagnosed as cholecystitis and retained placental products. Imaging studies suggested deep infiltrative endometriosis with extraovarian endometriotic lesions. Surgical exploration revealed a hemangioma within the right anterior broad ligament alongside peritoneal endometriosis lesions. The hemangioma itself expresses estrogen and progesterone receptors in stromal cells. The presence of steroid hormone receptors strongly suggests symptom alleviation during the menstrual cycle and the postpartum period. The coexistence of cavernous hemangioma and endometriosis in the broad ligament, previously unreported, and symptomatic overlap between the two conditions complicates diagnosis and management, emphasizing the need for comprehensive evaluation integrating clinical symptoms and imaging findings.

Viktor P. Baskakov: life, science, and heritage (on the 100th anniversary of his birth)

This article sheds light on the personal and professional paths of Professor Viktor Baskakov, who was an outstanding obstetrician-gynecologist, an endometriosis specialist, and the author of the first fundamental scientific works on endometriosis in Russia. The paper explores the milestones of the professor’s scientific career and discusses the peculiarities of clinical work and surgical techniques in the treatment of deep infiltrative endometriosis, in particular. In addition, new methods of management of the early postoperative period, as well as prevention and rehabilitation of gynecological patients are described. Viktor Baskakov was a talented teacher and mentor, a skilled surgeon, a competent scientific and clinical supervisor who had an innovative and bold view of the problems of treatment and diagnosis of endometriosis, which at that time were especially relevant and under-investigated. Special attention is paid to the many memories of colleagues and grateful patients of Professor Viktor Baskakov.

P-281 Surgery and IVF for diagnosed ovarian endometriosis and deep infiltrative endometriosis

Abstract Study question To evaluate the effectiveness of surgical treatment of endometrioid cysts and deep infiltrative endometriosis before an IVF program Summary answer Laparoscopic excision of deep infiltrative endometriosis has a positive effect on the reproductive function of women What is known already One of the most severe and aggressive manifestations of endometriosis is deep infiltrative endometriosis. Endometriosis is a socially significant disease that reduces a woman’s quality of life and affects reproductive health. Women with endometriosis often experience severe menstrual and non-menstrual pain affecting the lower abdomen, pelvis or lumbosacral region, profound dyspareunia, dyschezia and dysuria (Uimari et al., 2021) and infertility in 30–50% of cases (Prescott et al.., 2016). Patients with endometriosis suffer from chronic fatigue (Ramin-Wright et al., 2018) and have a higher risk of mental health problems (56.4%) than patients without endometriosis (43.6%) (Pope et al., 2015) Study design, size, duration The our institute is conducting a controlled, non-randomized, retro- and prospective study on genital endometriosis. The study period is from 2012 to the present. Participants/materials, setting, methods The study included 450 women with deep infiltrating endometriosis in combination with infertility All patients were divided into 4 groups Group 1 – 128 patients with deep infiltrative endometriosis, sent for IVF without surgery Group 2 – 297 patients with deep infiltrative endometriosis, initially referred for surgery Group 2a – 156 patients with ovarian cysts, sent for preliminary collection of eggs before surgery Group 2c – 141 patients with ovarian cysts, referred for surgery without prior egg retrieval Main results and the role of chance In group 1, the number of pregnancies occurred was 65.6% (84 women), in group 2a - 71.7% (112 women), in group 2 - 53.9% (76 women). Pregnancy occurred spontaneously in 18 (4.2%) women from group 2 after surgery. In group 2, four women, after three unsuccessful attempts at in vitro fertilization, became pregnant after using donor eggs - the results were excluded from the final pregnancy calculations. In terms of pregnancy, IVF with preliminary surgery (Me: 2.10; Q1-Q-3:0) had a statistically significant advantage compared to IVF without surgery (Me: 5.00; Q1-Q-3:0), and IVF with surgery without egg retrieval (Me:3.0; Q1-Q-3:0). The lowest statistically significant pregnancy rate was recorded during laparoscopic surgery without prior egg retrieval (Me: 6.95; Q1-Q-3:1). When performing a post-hoc analysis, a statistically significant shorter pregnancy time was also found when performing IVF with preliminary laparoscopy and egg freezing: group 1 (M: 126.25; SD111.1), group 2a (M: 79.97; SD: 19.785 ), group 2c (M: 130.50; SD: 82.149) (p = 0.000). During the period of observation of women for twelve years after surgery, 93% of patients noted an improvement in the quality of life and 63.7% of women on average achieved reproductive function after the IVF program for endometriosis. Limitations, reasons for caution no restrictions Wider implications of the findings The results of the IVF program for deep infiltrative endometriosis are statistically higher after surgery, but with preliminary cryopreservation of oocytes. The question of radical resection of the rectum in comparison with shaving when planning an IVF program remains open, which forms the planning of further research in this area. Trial registration number not applicable

Reproductive outcomes of infiltrative endometriosis after surgical treatment with assisted reproductive technologies (a clinical case)

Endometriosis is one of the most urgent problems of modern gynecology and reproductive medicine. About 40 % of women suffering from endometriosis of various localization are infertile. The use of drug therapy has not been proven to increase fertility. Currently, there is no consensus on the impact of surgical treatment on the effectiveness of assisted reproductive technologies.This article presents a clinical case of modern approache to the use of assisted reproductive technologies for endometriosis-associated infertility. The tactics of managing women with endometriosis is determined by its localization, the age of the patient, ovarian reserve, the duration of infertility, the therapy and its effectiveness, the condition of the fallopian tubes, as well as spermogram parameters. The correctly chosen management strategy for this patient made it possible to achieve not only a clinical pregnancy, but also the birth of a healthy child.

Exploring the feasibility of indocyanine green fluorescence for intraoperative ureteral visualisation in robotic transvaginal natural orifice transluminal endoscopy surgery during endometriosis resection.

To assess the feasibility of use of indocyanine green (ICG) in identifying and minimising urinary tract injury during surgical resection of endometriosis through robotic transvaginal natural orifice transluminal endoscopy surgery (RvNOTES). We conducted a retrospective case series in two academic tertiary care hospitals. We examined 53 patients who underwent RvNOTES hysterectomy with planned endometriosis resection. The study involved 53 patients undergoing RvNOTES with ICG fluorescence for endometriosis resection. Mean patient age was 37.98±6.65years. Operative time averaged 181.32±53.94min, with estimated blood loss at 45.57±33.62mL. Postoperative stay averaged 0.23±0.47days. No ICG-related complications occurred. No complications occurred with ICG fluorescence in RvNOTES. It appears to be a safe option for ureteral localisation and preservation. ICG fluorescence is widely used in diverse medical specialities for identifying ureters during complex surgeries. Larger studies are needed to firmly establish its advantages in intraoperative ureteral visualisation during RvNOTES for deep infiltrative endometriosis.

Bladder endometriosis – diagnostic and management challenges: A case report

Background: Urinary tract endometriosis (UTE) is the presence of endometriotic implants in the bladder,ureter, kidneys, or urethra. It affects ~1% of women with endometriosis and occurs more commonlyamong those with deep infiltrative endometriosis. Bladder endometriosis is the most commonpresentation, comprising 85% of cases. Concomitant involvement of the bladder and ureter is rare,comprising 1.4% of all cases. The clinical presentation involves lower urinary tract symptoms, thatworsen during menses. Timely diagnosis and treatment are crucial in ameliorating symptoms andpreventing complications, such as obstructive nephropathy. This is a case of bladder endometriosis withureteral involvement, outlining management challenges, reviewing evidence on managementapproaches, and highlighting the experience gained from this case in managing complex UTE.Case presentation: A 38-year-old female presented with a longstanding history of pelvic pain, dysuria,and new-onset voiding difficulty. She had undergone two prior surgical procedures for endometriosis,including a total abdominal hysterectomy. Her physical examination was normal. Ultrasound revealed a3-cm intracavitary bladder mass, which was described as likely endometriosis on magnetic resonanceimaging. On cystoscopy the mass was noted to be larger, encasing the left ureteric meatus. Alaparoscopic cystostomy was performed, with partial resection of the mass and placement of a temporaryureteric stent. After three months of medical treatment with dienogest, cystoscopy revealed a significantreduction in size with sub-centimeter residual avascular tissue. This was resected avoiding the ureter andureteric meatus. A new ureteric stent was placed. A repeat cystoscopy three months later revealed goodhealing with no residual endometriosis. The stent was removed, and a retrograde pyelogram confirmedno meatal stenosis or ureteric obstruction. She has remained symptom-free.Conclusion: Medical and surgical options are available for bladder endometriosis, with partialcystectomy being the gold standard. The initial approach is dependent on the size of the lesion and theextent of ureteric involvement. A staged approach that combines medical or surgical management canensure optimal outcomes while reducing surgery-associated morbidity in complex cases.

Non-invasive diagnostics of endometriosis based on plasma miRNA expression

Aim. To develop a method for noninvasive diagnosis of external genital endometriosis based on plasma microRNA concentrations.Materials and Methods. 80 women of reproductive age who were admitted to the gynecological department for routine laparoscopy were retrospectively examined, according to the results of which and histological examination, the patients were divided into 2 groups: the main group — 54 patients with laparoscopically and histologically confirmed external genital endometriosis (EGE); the control group — 26 patients without EGE. Before laparoscopy, a blood sample was taken from all patients for a molecular-biological study of the expression of 10 microRNAs: miR-183, miR-125b, miR-126, miR-16, miR-15a, miR-200a, miR-20a, miR-21, miR-222 and miR-29b. Identification of the studied and normalizing RNAs (U6 RNA and 103a microRNA) was performed according to the method of Chen et al. The presented values of the expression of the studied microRNAs are given in the form of 2-ΔCt. The expression ratio is given in the form of 2-ΔCt (main)/2-ΔCt (control), if the expression in the group of patients with endometriosis exceeded that in the control group, and in the form of 2-ΔCt (control)/2-ΔCt (main), if vice versa.Results. Comparison of the expression of 10 mi-croRNAs between the two groups revealed statistically significant differences only in miR-183: its expression in patients with EGE was statistically 1.5 times higher than that in women of the control group (p=0.017).We have not detected a difference in the expression of mir-200a, while according to other researchers, representatives of the mir-200 family are among the most frequent whose expression changes with endometriosis. MIR-16 expression also did not differ statistically among the patients we examined, whereas a group of American colleagues revealed its increase in patients with endometriosis and with endometriosis-associated ovarian tumors. We found no difference in mir-21 expression. The results of other researchers are contradictory: some found its increase in endometrioid cysts compared with eutopic endometrium, an increase in the epithelium of the fallopian tubes with their endometriosis compared with unaffected; others did not reveal a difference between the eutopic endometrium of endometriosis patients and healthy women, but showed a decrease in expression in peritoneal foci and foci of deep infiltrative endometriosis compared with eutopic endometrium.The expression of mir-222 was reduced in the patients we examined with endometriosis, which goes against the existing ideas about the pro-oncogenic role of this microRNA. An increase in its expression in cancer of the stomach, bladder, liver, lungs, breast, endometrium, ovaries is described. At the same time, the oncosuppressive effect of mir-222 is also known in prostate cancer, squamous cell carcinoma of the oral cavity.Conclusion. Taking into account the revealed statistically significant difference in microRNA expression by ROC analysis, we determined their effectiveness and specificity in the diagnosis of EGE. Of course, further studies with a large contingent of patients are needed to confirm the diagnostic value of these biomarkers. In addition, our study did not allow us to establish a statistical difference in microRNA expression in patients with impaired fertility. But it is the test that makes it possible to differentiate female infertility — associated with endometriosis and without it, as a rule, tubal-peritoneal genesis — that will become a key tool in the personalized management of patients with infertility.In our work, the distribution of patients by stages of EGE turned out to be uneven (there were no women with stage I at all) and it was not possible to establish a statistical difference in microRNA expression depending on the "length of service" of the disease.

Predicting the risk of decreased ovarian reserve after surgical treatment of patients with deep infiltrative endometriosis using artificial intelligence

Predicting the risk of decreased ovarian reserve after surgical treatment of patients with deep infiltrative endometriosis using artificial intelligence

First study of using fluorescent visualization of deep infiltrative endometriosis in laparoscopy

First study of using fluorescent visualization of deep infiltrative endometriosis in laparoscopy

Pilot study of treatment of patients with deep infiltrative endometriosis with methotrexate carried in lipid nanoparticles.

Previously, lipid nanoparticles (LDE) injected in women with endometriosis were shown to concentrate in the lesions. Here, the safety and feasibility of LDE carrying methotrexate (MTX) to treat deep infiltrating endometriosis was tested. Prospective pilot study. Perola Byington Hospital Reference for Women's Health. Eleven volunteers (aged 30-47years, BMI 26.15 ± 6.50kg/m2) with endometriosis with visual analog scale pelvic pain scores (VAS) > 7 and rectosigmoid lesions were enrolled in the study. Three patients were treated with LDE-MTX at single intravenous 25mg/m2 dose of MTX and eight patients with two 25mg/m2 doses with 1-week interval. Clinical complaints, blood count, and biochemistry were analyzed before treatment and on days 90, 120, and 180 after LDE-MTX administration. Endometriotic lesions were evaluated by pelvic and transvaginal ultrasound (TVUS) before treatment and on days 30 and 180 after LDE-MTX administration. No clinical complaints related with LDE-MTX treatment were reported by the patients, and no hematologic, renal, or hepatic toxicities were observed in the laboratorial exams. FSH, LH, TSH, free T4, anti-Müllerian hormone, and prolactin levels were also within normal ranges during the observation period. Scores for deep dyspareunia (p < 0.001), chronic pelvic pain (p = 0.008), and dyschezia (p = 0.025) were improved over the 180-day observation period. There was a non-significant trend for reduction of VAS scores for dysmenorrhea. Bowel lesions by TVUS were unchanged. No clear differences between the two dose levels in therapeutic responses were observed. Results support the safety and feasibility of using LDE-MTX in women with deep infiltrating endometriosis as a novel and promising therapy for the disease. More prolonged treatment schemes should be tested in future placebo-controlled studies aiming to establish the usefulness of this novel nanomedicine approach.

Intestinal endometriosis: A rare clinical image of sigmoid presentation

A 47-year-old female patient with a history of umbilical endometriosis and iron deficiency anemia presented to the gastroenterology department with a year-long complaint of abdominal pain, rectal pain, and hematochezia during menstruation. The physical examination and the results of laboratory studies of the patient were unremarkable. A contrast MRI of the abdomen revealed pathological thickening of 1.5 cm in the middle segment of the rectum and chocolate cysts on both ovaries, and the patient was referred for colonoscopic evaluation with suspicion of infiltrative endometriosis or colon neoplasm. An upper endoscopy and colonoscopy were performed. An actively bleeding mass in sigmoid colon, partially restricting the lumen but allowing for the passage of the video colonoscope, was observed (Figure 1A,1B: Sigmoid lesion). Biopsy specimens from the sigmoidal mass showed features consistent with endometriosis. A diagnosis of endometriosis was made. The patient underwent surgical intervention by sigmoid colon resection, hysterectomy, and bilateral oophorectomy. The complaints ceased on postoperative follow-up.

10255 A Sustainable Approach for Navigating Complex Endometriosis: Bladder Peritonectomy of Deeply Infiltrative Endometriosis (DIE)

10255 A Sustainable Approach for Navigating Complex Endometriosis: Bladder Peritonectomy of Deeply Infiltrative Endometriosis (DIE)

Potential Significance of Serum Autoantibodies to Endometrial Antigens, α-Enolase and Hormones in Non-Invasive Diagnosis and Pathogenesis of Endometriosis.

The objective of the study was to evaluate the profile of serum autoantibodies and their diagnostic and pathogenetic significance in ovarian endometrioma (OEM) and deep infiltrative endometriosis (DIE). The study enrolled 74 patients with endometriosis (Group 1), including 53 patients with OEM (Subgroup 1a); 21 patients with DIE without ovarian lesions (Subgroup 1b); and 27 patients without endometriosis (Group 2). The diagnosis was confirmed by laparoscopic surgery and histologic examination of resected tissues. Antibodies (M, G) to tropomyosin 3 (TPM), tropomodulin 3 (TMOD), α-enolase (ENO), estradiol (E2), progesterone (PG), and human chorionic gonadotropin (hCG) were identified in blood serum using modified ELISA. In endometriosis, antibodies to endometrial antigens, hormones, and ENO were detected more often than antiphospholipid and antinuclear antibodies. Higher levels of IgM to TPM, hCG, E2, and PG and IgG to TMOD, ENO, E2, and hCG were found in Subgroup 1a compared to Group 2. IgM to TPM, hCG, E2, PG, and IgG to E2 and ENO had a high diagnostic value for OEM (AUC > 0.7), with antibodies to TPM having the highest sensitivity and specificity (73.6% and 81.5%). In Subgroup 1b, only the levels of IgM to TPM and hCG were higher than in Group 2. These antibodies had a high diagnostic value for DIE. Thus, endometriosis is associated with autoantibodies to endometrial antigens, α-enolase, steroid, and gonadotropic hormones. A wider spectrum of antibodies is detected in OEM than in DIE. These antibodies have a high diagnostic value for OEM and DIE and potential pathogenetic significance for endometriosis and associated infertility.

The role of the anti-Müllerian hormone/anti-Müllerian hormone receptor type II signaling pathway in the eutopic and ectopic endometrium in patients with deep endometriosis: A cross-sectional study

Aim. To analyze the profile of anti-Mllerian hormone (AMH) and the expression level of the transmembrane AMH receptor type II (AMHRII) in the eutopic and ectopic endometrium of patients with deep infiltrative endometriosis (DIE).&#x0D; Materials and methods. A comparative analysis of AMHRII expression in epithelial and stromal cells of eutopic and ectopic endometrial samples and the level of serum AMH in patients of reproductive age with DIE (n=50) and tuboperitoneal infertility (n=9) was performed.&#x0D; Results. AMHRII expression in eutopic endometrial stromal cells of DIE patients was significantly higher compared to glandular cells in all study groups (p0.5). AMHRII expression was found to be significantly higher in glandular cells of the eutopic endometrium compared to the ectopic endometrium of pelvic peritoneal foci in DIE patients: 1.600.77 and 1.090.68 points, respectively (p=0.001).&#x0D; Conclusion. The inhibitory effect of AMH on cell proliferation and the proven expression of AMHRII by eutopic and ectopic endometrioid cells may indicate the role of AMH in the pathogenesis of endometriosis and endometriosis-associated infertility.

«Всегда в моде». Неоклассика, или Излюбленные локализации эндометриоза

Endometriosis continues to be an unsolved/unsolvable problem of modern gynecology. There are only 3 most common clinical phenotypes of this disorder: superficial peritoneal endometriosis, cystic ovarian endometriosis and deeply infiltrative endometriosis. In view of significantly reduced quality of life in patients with endometriosis resulting from algological symptoms and endometriosis-associated infertility, it is necessary to consider the features of clinical management of a patient with the “favorite” endometriosis localization to provide effective clinical management and improve the therapy efficacy.

MHT in women with endometriosis

The relation between Menopausal Hormonal Treatment MHT and endometriosis rises several debates in relation with the characteristics of each. From the point of view of view of MHT the individualized balance of risks and benefits, which seems to be the key of the approach of this therapy should be apply in each and every case. The profile of a women with a symptomatic endometriosis, in generally marked by pain, infertility and/or several series surgeries in the pelvic area, might be one marked by an early menopause, symptomatic and with several risks related to menopausal syndrome, osteoporosis and poor quality of life, which makes them candidates for MHT. In the same time, while we individualize the treatment, known or unknown endometriosis seems to offer an increased risk for endometrial recurrence and, what is the more debatable problem increase the risks for endometriosis hyperplasic transformation and association with increased risk of some forms of ovarian cancer. The date and the results of the data till should be based on many variables like – endometriosis type – deep infiltrative which has lower risk for malignant transformational, compared with endometrioma forms, or with ovarian lesions, with or without surgery and which type of surgeries. In the same time modern MHT use the minimal effective dose, with lower effective doses of hormones, mostly natural forms, without an aim to replace the premenopausal levels. One study underlined a safer profile, from this point of view, brings estrogen – progestogen combination, and tibolone, versus estrogen alone. An utmost importance has bilateral salping-oophorectomy and residual disease from surgery description - using revised Enzian classification for Deep Infiltrative Endometriosis and description of endometrioma location and surgical approach.