Giorgio Aimi

Comparison of a levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study

Abstract Objective To determine whether the frequency and severity of dysmenorrhea are reduced in women with symptomatic endometriosis in whom a levonorgestrel-releasing intrauterine device (Lng-IUD) is inserted after operative laparoscopy compared with those treated with surgery only. Design Open-label, parallel-group, randomized, controlled trial. Setting A tertiary care and referral center for patients with endometriosis. Patient(s) Parous women with moderate or severe dysmenorrhea undergoing first-line operative laparoscopy for symptomatic endometriosis. Intervention(s) Randomization to immediate Lng-IUD insertion or expectant management after laparoscopic treatment of endometriotic lesions. Main outcome measure(s) Proportions of women with recurrence of moderate or severe dysmenorrhea in the two study groups 1 year after surgery and overall degree of satisfaction with treatment. Result(s) Moderate or severe dysmenorrhea recurred in 2 of 20 (10%) subjects in the postoperative Lng-IUD group and 9/20 (45%) in the surgery-only group. Thus, a medicated device inserted postoperatively will prevent the recurrence of moderate or severe dysmenorrhea in one out of three patients 1 year after surgery. A total of 15/20 (75%) women in the Lng-IUD group and 10/20 (50%) in the expectant management group were satisfied or very satisfied with the treatment received. Conclusion(s) Insertion of an Lng-IUD after laparoscopic surgery for symptomatic endometriosis significantly reduced the medium-term risk of recurrence of moderate or severe dysmenorrhea.

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

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

Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized, controlled trial

OBJECTIVE To evaluate the efficacy of laparoscopic resection of the uterosacral ligaments in women with endometriosis and predominantly midline dysmenorrhea. DESIGN Randomized controlled trial. SETTING Two academic departments. One hundred eighty patients undergoing operative laparoscopy as first-line therapy for stage I to IV symptomatic endometriosis. INTERVENTION(S) Operative laparoscopy including uterosacral ligament resection or conservative surgery alone. MAIN OUTCOME MEASURE(S) Proportion of women with recurrence of moderate or severe dysmenorrhea 1 year after surgery. RESULT(S) No complications occurred. Among the patients who were evaluable 1 year after operative laparoscopy, 23 of 78 (29%) women who had uterosacral ligament resection and 21 of 78 (27%) women who had conservative surgery only reported recurrent dysmenorrhea. The corresponding numbers of patients at 3 years were 21 of 59 (36%) women and 18 of 57 (32%) women, respectively. Time to recurrence was similar in the two groups. Pain was substantially reduced, and patients in both groups experienced similar and significant improvements in health-related quality of life, psychiatric profile, and sexual satisfaction. Overall, 68 of 90 (75%) patients in the uterosacral ligament resection group and 67 of 90 (74%) patients in the conservative surgery group were satisfied at 1 year. CONCLUSION(S) Addition of uterosacral ligament resection to conservative laparoscopic surgery for endometriosis did not reduce the medium- or long-term frequency and severity of recurrence of dysmenorrhea.

Is cystic ovarian endometriosis an asymmetric disease

Objective To investigate whether asymmetry exists in the left‐ and right‐handed distribution of ovarian cystic lesions in a large series of women with endometriosis.

Menstrual characteristics in women with and without endometriosis

Objective To assess menstrual blood loss and other menstrual characteristics prospectively in women with and without endometriosis. Methods Three hundred fifteen premenopausal women undergoing laparoscopy for various reasons were asked to complete a pictorial blood loss assessment chart devised by Higham et al to evaluate menstrual flow on which the monthly score has been demonstrated to correlate directly with uterine blood loss measured by the alkaline hematin method. In addition, cycle length and flow duration were recorded. The women also were asked to grade dysmenorrhea severity using a 100-mm visual analogue and a 0-3-points verbal rating scale. Results One hundred sixty-three women had endometriosis, and 152 did not. The latter group comprised 59 women with a normal pelvis, 36 with nonendometriotic ovarian cysts, 29 with chronic pelvic inflammatory disease, and 28 with miscellaneous conditions. The median [interquartile range] pictorial blood loss assessment chart score was 110 [66.5–156.5] in women with endometriosis and 84 [56–129] in those without the disease (P = .007); 87 out of 163 (53%) women with endometriosis had a menstrual chart score equal to or greater than 100 compared with 56 out of 152 (37%) of those without (χ21 = 8.02, P = .005; difference = 16%, 95% confidence interval, 6%, 28%). Menstrual flow duration was slightly longer in women with endometriosis (mean difference, 0.33 days). Dysmenorrhea visual analogue and verbal rating scores were significantly higher in the endometriosis than the nonendometriosis group. Conclusion According to a visual chart, women with endometriosis had heavier menstrual flow and a significantly higher rate of abnormal menstrual scores than those without the disease.

Deep endometriosis conundrum: evidence in favor of a peritoneal origin

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

Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis.

Ureteral or vesical endometriotic lesions affect about 1% of women with endometriosis. The diagnosis may be difficult when specific symptoms are lacking. A delay in diagnosis can lead to significant morbidity. An adequate comprehension of the circumstances in which ureteral and vesical endometriosis present or should be suspected, aided by advances in imaging techniques and laparoscopic surgery, may allow a significant progress in the treatment of these conditions. The pathogenesis, diagnosis, and treatment of ureteral and vesical endometriosis are reviewed, with the aim of increasing the degree of awareness of the clinicians and helping in devising an adequate clinical management plan for the lesser understood aspects of the disease. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this educational activity, the participant should be better able to explain the most likely pathogenesis of ureteral and vesical endometriosis, recall the clinical presentation and risk factors for endometriosis of the bladder and ureter, and summarize treatment strategies for endometriosis of the bladder and ureter.

Individual patient data meta-analysis of randomized evidence to assess the effectiveness of laparoscopic uterosacral nerve ablation in chronic pelvic pain

BACKGROUND There have been conflicting results in randomized trials of the effects of laparoscopic uterosacral nerve ablation (LUNA) in chronic pelvic pain. Our objective was to perform a meta-analysis using individual patient data (IPD) to provide the most comprehensive and reliable assessment of the effectiveness of LUNA. METHODS Electronic searches were conducted in the Medline, Embase, PsycInfo and Cochrane Library databases from database inception to August 2009. The reference lists of known relevant papers were searched for any further articles. Randomized trials comparing LUNA with no additional intervention were selected and authors contacted for IPD. Raw data were available from 862 women randomized into five trials. Pain scores were calibrated to a 10-point scale and were analysed using a multilevel model allowing for repeated measures. RESULTS There was no significant difference between LUNA and No LUNA for the worst pain recorded over a 12 month time period (mean difference 0.25 points in favour of No LUNA on a 0-10 point scale, 95% confidence interval: -0.08 to 0.58; P = 0.1). CONCLUSIONS LUNA does not result in improved chronic pelvic pain.

Metroplasty for the complete septate uterus: Does cervical sparing matter?

STUDY OBJECTIVES To verify if section of the cervical septum facilitates hysteroscopic metroplasty of a complete septate uterus, and to determine if this technique is associated with intraoperative bleeding or postoperative obstetric complications. DESIGN Prospective, observational study. SETTING Academic department and tertiary care referral center for malformations of the female genital tract. PATIENTS Ten women with complete septate uterus. INTERVENTIONS The cervical portion of the septum was incised with Metzenbaum scissors and the corporeal portion with microscissors under hysteroscopic guidance. MEASUREMENTS AND MAIN RESULTS Mean +/- SD operating time for the entire procedure was 24 +/- 7 minutes, with a mean distention fluid deficit of 480 +/- 190 ml. No significant bleeding was encountered during cervical septum incision. At follow-up hysteroscopy, the cervices were competent, and no women experienced second-trimester abortion or premature delivery. CONCLUSIONS Section of the cervical septum with scissors is simple, rapid, and safe, facilitates corporeal hysteroscopic metroplasty, and may be considered a valid procedure to correct a completely septate uterus.

Meta‐analysis using individual patient data from randomised trials to assess the effectiveness of laparoscopic uterosacral nerve ablation in the treatment of chronic pelvic pain: a proposed protocol

Background  Currently, there are a number of clinical trials, but no international collaboration for collating research on effectiveness of laparoscopic uterosacral nerve ablation (LUNA) for alleviating chronic pelvic pain.