Superficial Peritoneal Endometriosis Research Articles

Efficacy of excision versus ablation for improving endometriosis related pain: A systematic review and meta-analysis

Background: Surgical treatment of superficial peritoneal endometriosis includes excision or ablation. Controversy exists about which method is better for providing pain relief. We performed a meta-analysis of randomized control trials (RCTs) comparing the efficacy of excision versus ablation for improving the most frequently encountered endometriosis pain symptoms: dysmenorrhea, dyspareunia, non-cyclic pelvic pain, and dyschezia. Methods: A search from inception to May 2020 was conducted in PubMed, MEDLINE, Clinicaltrials.gov, Cochrane Central Register of Controlled Trials, and Web of Science. RCTs comparing excision versus ablation for peritoneal endometriosis were included if they assessed dysmenorrhea, dyspareunia, dyschezia, and pelvic pain/non-menstrual pain. Exclusion criteria included extra-peritoneal endometriosis or endometriomas, and non-English publications. Publications were assessed for risk of bias and quality of evidence using Cochrane risk of bias tool (RoB 2) and GradePro. Results: Of the 2025 records identified initially, four met inclusion criteria. The sample sizes of the included studies ranged from 24 to 133 participants. The excision and ablation groups included 204 participants each. There was no difference after excision or ablation for dysmenorrhea when comparing the mean change in pain scores from baseline to 12 months after surgery (−0.31, 95% CI −1.66, 1.04, p = 0.65), dyspareunia (−0.24, 95% CI −1.78, 1.30, p = 0.76), dyschezia (−0.72, 95% CI −1.94, 0.50, p = 0.25), or non-cyclic pain (−0.78, 95% CI −2.47, 0.91, p = 0.37). Conclusions: We found low to moderate quality evidence suggesting that neither excision nor ablation is superior in reduction of endometriosis-related pain up to 12 months after surgery.

Association Between Endometriosis Phenotype and Preterm Birth in France

Endometriosis is an inflammatory disease with a heterogeneous presentation that affects women of childbearing age. Given the limitations of previous retrospective studies, it is still unclear whether endometriosis has adverse implications for pregnancy outcomes. To evaluate the association between the presence of endometriosis and preterm birth and whether the risk varied according to the disease phenotype. This cohort study with exposed and unexposed groups was conducted in 7 maternity units in France from February 4, 2016, to June 28, 2018. Participants included women with singleton pregnancies who were followed up before 22 weeks' gestation along with their newborns delivered at or after 22 weeks' gestation. The final follow-up occurred in July 2019. Data were analyzed from October 7, 2020, to February 7, 2021. Women in the endometriosis group had a documented history of endometriosis and were classified according to 3 endometriosis phenotypes: isolated superficial peritoneal endometriosis (SUP), ovarian endometrioma (OMA; potentially associated with SUP), and deep endometriosis (DE; potentially associated with SUP and OMA). Women in the control group did not have a history of clinical symptoms of endometriosis before their current pregnancy. The primary outcome was preterm birth between 22 weeks and 36 weeks 6 days of gestation. Association between endometriosis and the primary outcome was assessed through univariate and multivariate logistic regression analyses and was adjusted for the following risk factors associated with preterm birth: maternal age, body mass index (calculated as weight in kilograms divided by height in meters squared) before pregnancy, country of birth, parity, previous cesarean delivery, history of myomectomy and hysteroscopy, and preterm birth. The same analysis was performed according to the 3 endometriosis phenotypes (SUP, OMA, and DE). Of the 1351 study participants (mean [SD] age, 32.9 [5.0] years) who had a singleton delivery after 22 weeks of gestation, 470 were assigned to the endometriosis group (48 had SUP [10.2%], 83 had OMA [17.7%], and 339 had DE [72.1%]) and 881 were assigned to the control group. No difference was observed in the rate of preterm deliveries before 37 weeks 0 days of gestation between the endometriosis and control groups (34 of 470 [7.2%] vs 53 of 881 [6.0%]; P = .38). After adjusting for confounding factors, endometriosis was not associated with preterm birth before 37 weeks' gestation (adjusted odds ratio, 1.07; 95% CI, 0.64-1.77). The results were comparable for the different disease phenotypes (SUP: 6.2% [3 of 48]; OMA: 7.2% [6 of 83]; and DE: 7.4% [25 of 339]; P = .84). This cohort study found no association between endometriosis and preterm birth, and the disease phenotype did not appear to alter the result. Monitoring the pregnancy beyond the normal protocols or changing management strategies for women with endometriosis may not be warranted to prevent preterm birth.

Immunolocalization of stem/progenitor cell biomarkers Oct-4, C-kit and Musashi-1 in endometriotic lesions.

Human endometrium harbors stem/progenitor cells (SPCs) that may contribute to the establishment of endometriosis when seeded outside the uterus. Oct-4, C-kit and Musashi-1 are some of the many proteins used to characterize SPCs, but their association with endometriosis is uncertain. In this study, specimens of normal endometrium (n = 12), eutopic endometrium from women with endometriosis (n = 9), superficial peritoneal endometriosis (SUP, n = 12) and deep endometriosis (DE, n = 13) lesions were evaluated for localization and intensity of immunostaining for Oct-4, C-kit and Musashi-1. The three markers were abundantly expressed in normal endometrium, eutopic endometrium from endometriosis patients, SUP and DE specimens. Oct-4 and C-kit expression did not vary across groups as regards intensity or frequency. C-kit staining signal was seldom detected in vascular endothelium of normal or eutopic endometrium from endometriosis patients; however, it was positive in 67% of the SUP lesions and in 25% of the DE lesions (p = 0.042). Musashi-1 was expressed in some endometriotic glands as cell clusters, but its signal was similar between the four types of tissue (p = 0.971) CONCLUSION: The wide distribution of Oct-4, C-kit and Musashi-1 in endometria of patients with and without endometriosis and in SUP and DE endometriotic lesions suggests that these markers are not suitable for the in situ characterization of endometrial SPCs and should not be taken as surrogates for the study of SPCs in the pathogenesis of endometriosis.

Ovarian Immobility at Transvaginal Ultrasound: An Important Sonographic Marker for Prediction of Need for Pelvic Sidewall Surgery in Women With Suspected Endometriosis.

To determine whether ovarian fixation at transvaginal ultrasound (TVU) is a marker for a need for laparoscopic pelvic sidewall surgery (ie,ureterolysis or dissection of adhesions involving the pelvic sidewall). The relationship between ovarian immobility at TVU with respect to endometriosis staging using the revised American Fertility Society (r-AFS) classification was also evaluated. Retrospective diagnostic accuracy study was performed in a tertiary referral hospital and two private hospitals. Sixty-six women with pelvic pain underwent detailed TVU preoperatively followed by laparoscopic endometriosis surgery. TVU ovarian mobility findings (ie, mobile versus fixed ovary) were compared to surgical findings, the need for laparoscopic pelvic sidewall surgery and r-AFS score (I-IV). Complete ultrasound and surgical data were available for 66 of 77 (86%) women. Twenty-six of 66 (40%) had isolated superficial peritoneal endometriosis, 15 of 66 (23%) had ovarian endometrioma (OE), 13 of 66 (20%) had pelvic deep endometriosis (DE). Twenty-seven of 66 (41%) had ovarian fixation at TVU. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of ovarian fixation at TVU for the prediction of need for laparoscopic pelvic sidewall surgery was 71%, 61%, 86%, 85%, and 62%, respectively (P=.0002). Ovarian fixation at TVU was significantly associated with the presence of ipsilateral OE, pouch of Douglas obliteration, pelvic DE nodules, and r-AFS stage III/IV (moderate/severe) endometriosis (all P-values <.05). Ovarian fixation at TVU appears to be a marker for moderate/severe endometriosis and the need for laparoscopic pelvic sidewall surgery. This sign may be a valuable "red flag" for identifying women at increased risk of requiring an advanced laparoscopic surgeon, and in turn, improve surgical planning.

P–326 Presence of adenomyosis at MRI in endometriosis women negatively affect live birth chances in IVF cycles

Abstract Study question What is the impact of adenomyosis and its magnetic resonance imaging (MRI) characteristics on live birth rate (LBR) in endometriosis-affected women undergoing in-vitro fertilization (IVF) treatment? Summary answer Among women undergoing IVF, the presence of adenomyosis at MRI, and especially T2 high signal-intensity spots within the myometrium have a negative impact on LBR. What is known already: Adenomyosis is a frequent gynecologic disease. With the development of imaging technics for the diagnosis (notably MRI), several adenomyosis phenotypes have been described and fertility issues seem variable according to the lesions characteristics. Moreover, on IVF outcomes, controversial results have been found in studies assessing the impact of adenomyosis. What make the impact-assessment of adenomyosis on fertility issues even more difficult is the frequent association with endometriosis, another known risk factor of infertility. Some data suggested that adenomyosis could worsen IVF prognostics, however there is no clear consensus about the impact of the adenomyosis on IVF outcomes in endometriosis affected-women. Study design, size, duration This was an observational study including phenotyped endometriosis patients, aged between 18 to 42 years, who underwent IVF/intra-cytoplasmic sperm injection (ICSI) treatment in a tertiary care center, from June 2015 through July 2018.Only women who had performed a pelvic MRI during the pre-therapeutic ART work-up, were retained for this study. The MRI data were interpreted by radiologists who had expertise in gynaecological MRI. Participants/materials, setting, methods A continuous series of 202 endometriosis affected women was included. The women were followed until four ART cycles had been completed, until delivery or until discontinuation of treatment before the completion of four cycles. The primary outcome was the delivery of one or more live infant(s) after up to four IVF/ICSI cycles. Patients and MRI characteristics were compared between women who gave a live birth and those without live birth. Main results and the role of chance The mean age of the included population was 32.5 ±3.7 years. 90.1% (182/202) had deep infiltrating endometriosis whereas only 5.4% (11/202) and 4.5% (9/202) had respectively isolated ovarian endometriosis (OMA) and superficial peritoneal endometriosis (SUP). The presence of adenomyosis (internal and/or external lesions) was found in 71.8% (145/202) of included women. The cumulative live birth rate was 57.4% (116/202). Women that gave birth (‘live birth +’) were significantly younger, (33.3±4.1 vs 32.0±3.3 p = 0.026) and had significant better ovarian reserve parameters (AMH, AFC). The presence of adenomyosis (internal and/or external lesions) (76/116 (65.5%) versus 69/86 (80.2%), p = 0.022) and the presence of T2 high-signal intensity myometrial spots (27/116 (23.3%) and 37/86 (43.0%), p = 0.003) were significantly less frequently found in the group of women ‘Live birth +’. After multivariate analysis, the presence of adenomyosis (OR: 0.48 95% CI (0.29–0.99) p = 0.048) and the presence of T2 high-signal intensity myometrial spots (OR: 0.43 95% CI (0.22–0.86) p = 0.018) were independently found to be associated with a decrease in cumulative chances of live birth. Limitations, reasons for caution The inclusion of patients from our referral center could constitute a possible selection bias, as those women may have suffered from particularly severe forms of adenomyosis ± endometriosis. Wider implications of the findings: In women presenting endometriosis, the practitioner should perform an appropriate imaging work-up searching for adenomyosis, to identify prognostic factors and to plan the strategy of patient management in the setting of ART. Trial registration number NA

P–310 Women with endometriosis achieve live birth after a similar number of embryo transfers independent of the endometriosis subtype

Abstract Study question How many embryo transfers are needed to achieve the first live birth in women with endometriosis depending on disease localisation? Summary answer The number of transfers needed to achieve live birth in women with endometriosis is independent from the disease’s subtype. What is known already Infertility is one of the leading symptoms in women with endometriosis. Endometriosis is also known to negatively impact in-vitro fertilization (IVF) outcome. A reduction of oocyte yield, especially of mature oocytes in women with endometrioma (OMA) and deep infiltrating endometriosis (DIE) has been shown. Inflammatory processes possibly affect folliculogenesis and oocyte development, maybe impeding embryo development and implantation. In contrast, even with fewer retrieved oocytes per cycle live birth rate was not affected. However, it is currently unknown if specific endometriosis subtypes could differentially affect IVF success. This would be relevant for a more targeted counseling regarding the treatment success. Study design, size, duration This is a single-center cohort study including women (N = 229) with embryo transfer cycles leading to live birth at the Bern University Hospital between 2010 and 2017. We only included women until they achieved the first live birth at our center. Participants/materials, setting, methods: We included 86 women with endometriosis and 143 women with male factor infertility serving as comparison group. We collected patient characteristics, details from the endometriosis surgery and reproductive treatment and outcomes from medical reports. We hierarchically classified the dominant endometriosis localizations as follows: deep infiltrating endometriosis (DIE, N = 21) &amp;gt; ovarian endometriosis (OMA, N = 35) &amp;gt; superficial peritoneal endometriosis (SUP, N = 30). We compared the number of embryo transfers needed to achieve a live birth. Main results and the role of chance Women with endometriosis were older (34.5 ± 3.9 years) than women from the control group (33.4 ± 3.9), p = 0.03. Body-mass-index, previous parity or Anti-Mullerian hormone level did not differ between the groups SUP, OMA, DIE or the comparison group. The number of necessary embryo transfer cycles to achieve a live birth did not differ between women with SUP (3.4 ± 2.6 embryo transfers), OMA (2.9 ± 2.0), DIE (3.0 ± 2.4) and the comparison group (2.9 ± 2.2), p = 0.59. IVF is beneficial in women with endometriosis, especially when OMA and/or DIE affect mobility of tubes and ovaries and spontaneous pregnancy is unlikely or impossible. This could account for the equal number of transfer cycles needed to achieve a live birth in women with OMA compared to the comparison group, even though the women with endometriosis were of older age. This is reassuring when counseling women with endometriosis. Limitations, reasons for caution We did not calculate cumulative pregnancy rate per cycle, because in Switzerland IVF treatment is at the patient’s own cost and therefore biased. We wanted to include all women with endometriosis, so fresh and thawing cycles were included. Women from the comparison group had no surgical exclusion of endometriosis. Wider implications of the findings: Our study suggests that the endometriosis subtype does not determine the embryo transfer success rate after IVF and therefore is less relevant for counseling. Individualized anti-inflammatory treatment before embryo transfer might positively affect the cycles’ outcome. Studies with a larger sample are required to be more conclusive on this issue. Trial registration number BASEC 2015–00235

Clinicopathological features of different subtypes in adenomyosis: Focus on early lesions.

BackgroundThe aim of this study is to investigate the clinicopathological features of intrinsic and extrinsic subtypes in adenomyosis. In particular, we focused on the early lesions of adenomyosis.MethodsThis is a single-center, prospective study of women who elected surgery for adenomyosis at the Department of Gynecology, Nara Medical University Hospital, Kashihara, Japan, from April 2008 to March 2018. Adenomyosis was histologically classified as intrinsic, extrinsic, and others, depending on the type of intramural growth. Adenomyosis that occurs at the inner and outer myometrium was defined as an intrinsic and extrinsic type, respectively.ResultsOne hundred eighty-nine patients with histologically confirmed adenomyosis were classified into three different types, 74 intrinsic type, 78 extrinsic type, and 37 other type. Compared to the intrinsic type, the extrinsic type was more likely to have endometriosis, including ovarian endometrioma (OMA), superficial peritoneal endometriosis (SUP), or deep infiltrating endometriosis (DIE). To further identify the clinicopathological features of early-stage adenomyosis, we focused only on patients with intrinsic and extrinsic types of adenomyosis with less than one-third of muscular layer infiltration. Patients with early-stage intrinsic adenomyosis were more likely to experience induced abortions. Patients with early-stage extrinsic adenomyosis were more likely to have endometriosis. The coexistence of endometriosis and the lack of induced abortion were independent predictors of extrinsic adenomyosis. Multivariate logistic regression analysis identified coexistence of endometriosis as independent predictors of the early stage extrinsic adenomyosis.ConclusionThe study suggests that there are at least two types of adenomyosis, where the intrinsic type is closely associated with a history of induced abortion, while the extrinsic type is strongly associated with endometriosis. Adenomyosis might be a gynecological disorder with complex pathogenesis implicating both traumatic and endometriotic factors.

Modern views on endometriosis surgery. Literature review

Endometriosis is a disease associated with the presence of tissue morphologically similar to the endometrium outside the uterine cavity and it is an important medical and social problem. Statistical analysis of the endometriosis prevalence is complicated by polymorphism of manifestations a gradual increase of symptoms and a long period of time from the first symptoms to diagnosis. Manifestations of endometriosis are chronic pain, algodismenorea, dyspareunia, decreased fertility. All these manifestations worsen the quality of life and do not allow a woman to realize her reproductive potential. The most common forms of endometriosis are superficial peritoneal endometriosis, endometrioid ovarian cysts and deep infiltrative endometriosis. Treatment tactics depends on the form and stage of disease, woman's age, presence or absence of reproductive plans, previous treatment. It is possible to use both medical and surgical methods of treatment. Surgical methods can be organ-preserving and radical. The optimal surgical approach should weigh the risks of the surgery itself and the likelihood of recurrence in the radicalism absence. Modern techniques of surgical intervention are considered as one of the main methods of endometriosis treatment. Severe forms of endometriosis are a serious challenge for the surgical team, as chronic inflammation and adhesions alter the normal pelvis anatomy. Such operations often require the involvement of surgeons, urologists and other specialists, and the decision about final operation scope is made during the operation. Endometriosis surgery aims at the maximum possible in each case, the removal of pathological foci, which leads to relief of pain and increase the likelihood of reproductive plans. This article describes the rational scope of surgical interventions and optimal strategies for the management of patients with various forms of endometriosis. The data of international researches of efficiency of various methods of surgical interventions, influence of degree of radicalism on a disease course, probability of recurrence and quality of patient’s life are resulted.

Imaging for evaluation of endometriosis and adenomyosis.

Endometriosis and adenomyosis are two frequent diseases that impair women's quality of life by causing pain and infertility. Both endometriosis and adenomyosis are heterogeneous diseases that manifest as different forms. Adenomyosis may be described as diffuse adenomyosis, focal adenomyosis especially of the outer myometrium and cystic adenomyoma. Endometriosis has three phenotypes: superficial peritoneal endometriosis (SUP), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). These two diseases are closely linked, and it is now clear that adenomyosis can either arise on its own or coexist with endometriosis. There is a strong clinical relationship between endometriosis and adenomyosis according to their respective phenotypes. Various classifications are available to describe both diseases. Transvaginal ultrasonography (TVUS) and/or pelvic magnetic resonance imaging (MRI) are the first examination performed when endometriosis or adenomyosis are suspected. These two imaging techniques, used in a combination manner, allow accurate description of both endometriosis and adenomyosis, to assess the diagnosis and to improve clinical and surgical care. In this review, we described the different imaging aspects of endometriosis and adenomyosis to help the less experienced radiologist or gynecologist in the diagnosis and evaluation of those diseases.

Laparoscopic treatment of isolated superficial peritoneal endometriosis for managing chronic pelvic pain in women: study protocol for a randomised controlled feasibility trial (ESPriT1)

BackgroundEndometriosis (where endometrial-like tissue is found outside the uterus) affects ~ 176 million women worldwide and can lead to debilitating pelvic pain. Three subtypes of endometriosis exist, with ~ 80% of women having superficial peritoneal endometriosis (SPE). Endometriosis is diagnosed by laparoscopy and, if SPE is found, gynaecologists usually remove it surgically. However, many women get limited pain relief from surgical removal of SPE. We plan to undertake a future large trial where women who have only SPE found at initial laparoscopy are randomly allocated to have surgical removal (excision or ablation) of SPE, or not. Ultimately, we want to determine whether surgical removal improves overall symptoms and quality of life, or whether surgery is of no benefit, exacerbates symptoms, or even causes harm. The primary objective of this feasibility study is to determine what proportion of women with suspected SPE undergoing diagnostic laparoscopy will agree to randomisation. The secondary objectives are to determine if there are differences in key prognostic parameters between eligible women that agree to be randomised and those that decline; how many women having laparoscopy for investigation of chronic pelvic pain are eligible for the trial; the range of treatment effects and variability in outcomes and the most acceptable methods of recruitment, randomisation and assessment tools.MethodsWe will recruit up to 90 women with suspected SPE undergoing diagnostic laparoscopy over a 9-month recruitment period in four Scottish hospitals and randomise them 1:1 to either diagnostic laparoscopy alone (with a sham port to achieve blinding of the allocation) or surgical removal of endometriosis. Baseline characteristics, e.g. age, index of social deprivation, ethnicity, and intensity/duration of pain will be collected. Participants will be followed up by online questionnaires assessing pain, physical and emotional function at baseline, 3 months, 6 months and 12 months.DiscussionRecruitment to a randomised controlled trial to assess the effectiveness of surgery for endometriosis may be challenging because of preconceived ideas about treatment success amongst patients and clinicians. We have designed this study to assess feasibility of recruitment and to inform the design of our future definitive trial.Trial registrationClincicalTrials.gov, NCT04081532StatusRecruiting

Adenomyosis, a Predictor of Endometriosis Severity? a Pilot Study.

Study Objective Are sonographic features of adenomyosis associated with the three endometriosis phenotypes, superficial peritoneal endometriosis (SPE), ovarian endometrioma (OE) and deep infiltrative endometriosis (DE)? Design This retrospective cohort study analyses the presence of sonographic features of adenomyosis in reproductive age women with suspected endometriosis who underwent laparoscopic surgery at Liverpool Hospital during 2018-20 period. Setting N/A Patients or Participants 73 women of reproductive age with suspected endometriosis (pelvic pain or infertility). Interventions Women underwent a specialized transvaginal ultrasound (TVUS) by a single expert sonologist, to diagnose deep endometriosis and adenomyosis using the IDEA (International Deep Endometriosis Analysis) and MUSA (Morphological Uterus Sonographic Assessment) diagnostic criteria. All women underwent laparoscopic surgery within 6 months of the TVUS by an advanced laparoscopic surgeon, who documented intraoperative and histopathological findings. Measurements and Main Results The mean age was 35 years. 53/73 (73%) women had endometriosis at laparoscopy. 20/73 (27%) women had features of adenomyosis on TVUS with 14/20 of these women having endometriosis. 6/14 (43%) had DE with pouch obliteration, 7/14 (50%) had SPE and 1/14 (0.1%) had OE. Overall, the most common feature of adenomyosis at TVUS for women with endometriosis was heterogenous myometrium. Echogenic subendometrial lines was the most common TVUS feature for women with DE, whereas heterogenous myometrium was the most frequent TVUS features for women with SPE. An irregular interrupted junctional zone was the most common TVUS feature in women without endometriosis. Conclusion Women with adenomyosis at TVUS appear to be at high risk (70%) of concurrent endometriosis. 43% of women with adenomyosis at TVUS had advanced endometriosis (DE w pouch obliteration), with echogenic subendometrial lines the most common sonographic feature of adenomyosis. Further studies are needed to confirm whether specific features of adenomyosis at TVUS are associated with endometriosis phenotype, which in turn may aid in surgical planning for these women.

Indocyanine green in the surgical management of endometriosis: A systematic review.

Endometriosis is a very common disease that affects up to 10% of the female population. The use of indocyanine green (ICG) dye has been proposed to allow the proper localization of endometriotic lesions during surgery. Our purpose is to offer an overview of near-infrared (NIR)-ICG in the surgical treatment of superficial peritoneal endometriosis and deep infiltrating endometriosis. Electronic databases were searched, including MEDLINE, Embase, Web of Science, Scopus, ClinicalTrial.gov, OVID and Cochrane Library. The studies were identified with the use of a mesh combination of the following keywords: "indocyanine green", "endometriosis", "deep endometriosis", "robotic surgery", "laparoscopy", "ureter", "rectosigmoid" from 2000 to May 2020. All articles describing the use of ICG applied to endometriosis surgery were considered for review. Only original papers that reported specific experience data on the topic were included. Moreover, video-articles were included in the analysis. Quality and risk of bias were evaluated by two authors, respectively. Fifty-three studies were reviewed and reviews or comment articles not reporting original data and original articles lacking specific data on the application of ICG in patients affected by endometriosis were excluded. The quality of the 17 studies included was assessed. Eight studies suggested the usefulness of NIR-ICG as a tool in the detection of endometriosis during surgery, and one randomized controlled trial and one prospective study did not confirm the advantage of its use. Eight studies found that NIR-ICG was useful for the evaluation of vascularization in intestinal anastomoses and ureterolysis after surgery for deep infiltrating endometriosis. NIR-ICG appears useful in the evaluation of vascularization in intestinal anastomoses after segmental resection, confirming its role even after ureterolysis for parametrial deep infiltrating endometriosis. However, its usefulness as a tool in the detection of endometriosis during surgery is inconsistent.

Emergency surgery for appendectomy and incidental diagnosis of superficial peritoneal endometriosis in fertile age women

Research questionThis study aimed to evaluate the presence of superficial peritoneal endometriosis (SUP) in women referred to emergency surgery for right iliac fossa (RIF) pain and undergoing an appendectomy, considering which factors may be useful to suspect and identify endometriosis. DesignAn observational case–control study was conducted on a group (n = 149) of fertile age women. After surgery, Group A was selected upon the diagnosis of endometriosis (n = 34); Group B (n = 115) represented the controls. Demographics, comorbidities and clinical findings were registered and analysed. ResultsAppendicitis of various grades of severity was diagnosed in all patients, but SUP was also identified in 23%, of which 14.7% also presented with endometriosis of the appendix. Women in Group A reported chronic pelvic pain, dysmenorrhoea, dyspareunia and oral contraceptive use more frequently. At multivariate analysis, factors associated with endometriosis were: age <40 years, autoimmune disorders, multiple allergies, abdominal chronic pain, associated gynaecological pain symptoms, Alvarado score ≤6, and inconclusive ultrasound findings. ConclusionsThe incidental finding of SUP in fertile age women presenting with an acute RIF pain and undergoing emergency surgery is a relevant observation. Clinical history and symptoms should guide surgeons in performing a correct diagnosis and in referring the patient to the gynaecology specialist.

Case Report -An Unusual Peritoneal Endometriotic Implant

Endometriosis is defined as ectopic presence of endometrial tissue outside of uterine cavity. Superficial peritoneal endometriosis is characterized by small superficial lesions modifying from white to dark brown shades. Dimension goes from few millimetres to 3 centimetres. We report a case of a 38 years old patient who has not had a signification in gynaecological pathology until five-six months before the gynecological check, when dysmenorrhea conditions associated at depth dyspareunia arose. Clinical and ultrasound investigations showed the presence of a pelvic cystic lesion, around 5 cm in diameter, diagnosed in the first instance as endometriotic cyst of the left ovary. The cystic lesion in the pelvis was confirmed by laparoscopic inspection. Really it was a large peritoneal implant (the left ovary was perfectly normal). The pathological report confirmed that a component of the lesion had nodules of florid endometriosis. It doesn’t exist ovarian cortex, but definitely a responsive mesothelium: the examined tissue has to be diagnosed with peritoneal endometriotic implant. Conclusions We refer to a case of peritoneal endometriotic implantation that has unusual dimensions (5 cm in diameter) late-onset in a woman who has experienced a specific symptomatology only in the last 6 months before the diagnosis

Peritoneal Fluid Cytokines Reveal New Insights of Endometriosis Subphenotypes.

Endometriosis is a common inflammatory gynecological disorder which causes pelvic scarring, pain, and infertility, characterized by the implantation of endometrial-like lesions outside the uterus. The peritoneum, ovaries, and deep soft tissues are the commonly involved sites, and endometriotic lesions can be classified into three subphenotypes: superficial peritoneal endometriosis (PE), ovarian endometrioma (OE), and deep infiltrating endometriosis (DIE). In 132 women diagnosed laparoscopically with and without endometriosis (n = 73, 59 respectively), and stratified into PE, OE, and DIE, peritoneal fluids (PF) were characterized for 48 cytokines by using multiplex immunoassays. Partial-least-squares-regression analysis revealed distinct subphenotype cytokine signatures—a six-cytokine signature distinguishing PE from OE, a seven-cytokine signature distinguishing OE from DIE, and a six-cytokine-signature distinguishing PE from DIE—each associated with different patterns of biological processes, signaling events, and immunology. These signatures describe endometriosis better than disease stages (p < 0.0001). Pathway analysis revealed the association of ERK1 and 2, AKT, MAPK, and STAT4 linked to angiogenesis, cell proliferation, migration, and inflammation in the subphenotypes. These data shed new insights on the pathophysiology of endometriosis subphenotypes, with the potential to exploit the cytokine signatures to stratify endometriosis patients for targeted therapies and biomarker discovery.

Recurrence Patterns after Surgery in Patients with Different Endometriosis Subtypes: A Long-Term Hospital-Based Cohort Study.

Recurrence of endometriosis after surgery constitutes a serious challenge. Whether there is an evolution of lesion subtypes with each recurrence and whether certain lesions subtypes tend to recur faster than others is not adequately addressed. Medical records of all patients who underwent surgery for endometriosis between 1997 and 2018 in the Department of Gynecology and Obstetrics, University of Bern, were reviewed. Inclusion criteria was surgically confirmed endometriosis recurrence, defined as a subsequent surgery for endometriosis after a previous complete surgical excision of endometriosis lesions. Three subtypes of endometriosis were defined: superficial peritoneal endometriosis (SUP), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). Time to recurrence and variation in endometriosis subtype between the first and recurrent surgeries were the primary outcome measures. Out of the 322 patients with recurrent surgery that were identified, for 234 of them, the endometriosis subtype at first surgery was confirmed and classified (SUP = 56, OMA = 124, DIE = 54). No statistically significant difference was found for time to recurrence between lesion subtypes. SUP compared to the other groups had a higher possibility of presenting with SUP at recurrence (Odds Ratio (OR): 3.65, 95% confidence interval (CI): 1.74–7.51) and OMA compared to the other groups had a higher possibility of presenting with OMA at recurrence (OR: 3.72, 95% CI: 2.04–6.74). Nevertheless, a large number of SUP patients subsequently presented with OMA (10/56: 17.9%) or DIE (27/56: 48.2%) lesions at recurrence. Similarly, a large number of OMA patients subsequently presented with DIE (49/124: 39.5%) lesions at recurrence. In conclusion, although SUP and OMA patients compared to the others are more likely to present with the same subtype at recurrence, increasing lesion subtype severity occurs in a substantial proportion of patients. Time to recurrence is independent from the lesion subtype at first surgery.

Superficial Peritoneal Endometriosis: Clinical Characteristics of 203 Confirmed Cases and 1292 Endometriosis-Free Controls

The aim of this study was to characterize a large sample of women with superficial peritoneal endometriosis (SUP) and no other types of endometriosis in order to test the association of SUP with gynecologic symptoms. We included 203 cases of histologically proven SUP and 1292 endometriosis-free controls diagnosed between January 2004 and July 2017. The participants were non-pregnant patients aged 18 to 42years submitted to a laparoscopy or laparotomy for a benign gynecologic condition. We excluded all cases of ovarian endometrioma, deep infiltrating endometriosis, and women who had previously undergone an endometriosis surgery. All patients underwent face-to-face interviews, thorough preoperative physical examination, and transvaginal ultrasound. Pain severity was assessed preoperatively through an 11-point numerical rating scale. The association of SUP with gynecologic symptoms was adjusted for potential confounders using multivariable logistic regression. The presence of SUP was associated with lower body weight (59.8 vs. 63.5kg) and body mass index (21.8 vs. 23.3kg/m2), and a higher frequency of smoking habit (41.6% vs. 32.8%) and of positive familial history of endometriosis (7.0% vs. 2.3%). Moreover, SUP was associated with an increased risk of primary infertility (adjusted prevalence ratio [PR] 1.83, 95% confidence interval [CI] 1.46-2.24), moderate to intense dysmenorrhea (PR 1.43, 95% CI 1.31-1.52), and moderate to intense deep dyspareunia (PR 1.50, 95% CI 1.25-1.75). In conclusion, inthis large surgical series, isolated SUP was independently associated to primary infertility and moderate to severe painful symptoms.

Migraine in relation with endometriosis phenotypes: Results from a French case-control study.

Studies have shown a significant association between migraine and endometriosis, but no study has explored the relationship between migraine and endometriosis phenotypes: Superficial peritoneal endometriosis, ovarian endometrioma, and deep infiltrating endometriosis. We conducted a case-control study using data collected from 314 women aged 18 to 42 years who had undergone surgery for benign gynecological conditions between January 2013 and December 2015. All women completed a self-administered headache questionnaire according to the IHS classification. Cases (n = 182) are women with histologically proven endometriosis and controls are women (n = 132) without endometriosis. Occurrence of migraine was studied according to endometriosis phenotypes. Migraine prevalence in cases was significantly higher compared with controls (35.2% vs. 17.4%, p = 0.003). The risk of endometriosis was significantly higher in migrainous women (OR = 2.62; 95% CI = 1.43-4.79). When we take into account endometriosis phenotypes, the risk of ovarian endometrioma and deep infiltrating endometriosis were significant (OR = 2.78; 95% CI = 1.11-6.98 and OR = 2.51; 95% CI = 1.25-5.07, respectively). In women with endometriosis, the intensity of chronic non-cyclical pelvic pain was significantly greater for those with migraine (visual analogic scale (VAS) = 3.6 ± 2.9) compared with the women without headache (VAS = 2.3 ± 2.8, p = 0.0065). Our study shows a significant association between migraine and endometriosis. In clinical practice, women of reproductive age who suffer from migraine should be screened for endometriosis criteria in order to optimise the medical and therapeutic care of this condition.

Surgical removal of superficial peritoneal endometriosis for managing women with chronic pelvic pain: time for a rethink?

Surgical removal of superficial peritoneal endometriosis for managing women with chronic pelvic pain: time for a rethink?

Not Having Been Breastfed May Protect Chinese Women From Developing Deep Infiltrating Endometriosis: Results From Subgroup Analyses of the FEELING Study

BackgroundThis study aimed to investigate potential factors, especially early-life exposures, associated with endometrioma (OMA) and/or deep infiltrating endometriosis (DIE) in Chinese women.MethodsThis is a subgroup analyses of the FEELING study, which was a case-control study that investigated the clinical, lifestyle, and environmental factors associated with OMA and/or DIE in China, Russia, and France. In this subgroup analysis, the data for the Chinese participants were further analyzed using logistic regression model.ResultsAll women (N = 546) had fully completed the questionnaire. The mean age of the participants was 31.8 (range: 18–41) years. Univariable analysis showed that noncyclic chronic pelvic pain, dysmenorrhea intensity class, and whether breastfed during infancy were distributed differently between patients with OMA or DIE and those with no endometriosis (non-EM) or superficial peritoneal endometriosis (SUP; P <.05). Multivariable analysis revealed that not having been breastfed was a protective factor against OMA and DIE (odds ratio [OR] = 0.33, 95% confidence interval [CI]: 0.16-0.69). Further analysis indicated not having been breastfed was a protective factor for DIE compared with non-EM (OR = 0.13, 95% CI: 0.02–0.88) and with OMA + SUP (OR = 0.19, 95% CI: 0.04-0.85) but was not a protective factor for OMA compared with non-EM (OR = 0.66, 95% CI: 0.32-1.36) and with SUP (OR = 0.63, 95% CI: 0.31-1.30).ConclusionThis is the first study suggesting that not having been breastfed might protect against DIE in Chinese women.