Giovanni Battista Candiani

Stage and localization of pelvic endometriosis and pain

We analyzed the prevalence of dysmenorrhea, pelvic pain, and dyspareunia in relation to the disease stage in 160 women with endometriosis but no other associated pelvic disease who underwent their first gynecologic surgery (laparoscopy or laparotomy) at the First Obstetric and Gynecology Clinic of the University of Milan between 1985 and 1987. Dysmenorrhea was reported by 78% of the patients, pelvic pain by 39%; and deep dyspareunia by 32%. No relation was found between severity of the pain symptoms and stage of the disease or site of the endometriotic lesions.

Risk of recurrence after myomectomy

Summary. The risk of recurrence of uterine myomas was analyzed in 622 patients who underwent myomectomy between 1970 and 1984 at the First Department of Obstetrics and Gynecology of the University of Milan. The cumulative 10‐year recurrence rate was 27%, and this increased steadily up to the end of the observation period. Differences were not observed in frequency of recurrence by age at diagnoses or by the site of the myomas at surgery. Patients with a single myoma tended to experience a lower rate, but this finding was not statistically significant. Women who gave birth to a child after myomectomy had a 10‐year recurrence rate of 15%, against 30% for those who did not; this difference was statistically significant.

Presacral neurectomy for the treatment of pelvic pain associated with endometriosis: A controlled study

OBJECTIVE Our objective was to evaluate the efficacy of presacral neurectomy combined with conservative surgery for the treatment of pelvic pain associated with endometriosis. STUDY DESIGN In a randomized, controlled study performed in a tertiary institution 71 patients with moderate or severe endometriosis and midline dysmenorrhea were randomly assigned to conservative surgery alone (n = 36) or conservative surgery and presacral neurectomy (n = 35). Main outcome measures were relief of dysmenorrhea, pelvic pain, and deep dyspareunia after surgery according to a multidimensional and an analog pain scale. RESULTS Presacral neurectomy markedly reduced the midline component of menstrual pain, but no statistically significant differences were observed between the two groups in the frequency and severity of dysmenorrhea, pelvic pain, and dyspareunia in the long-term follow-up. After presacral neurectomy, constipation developed or worsened in 13 patients and urinary urgency occurred in three and a painless first stage of labor in two. CONCLUSION Presacral neurectomy should be combined with conservative surgery for endometriosis only in selected cases.

Double uterus, blind hemivagina, and ipsilateral renal agenesis: 36 cases and long-term follow-up

Objective To review the experience of the Milan University First Department of Obstetrics and Gynecology in patients with double, didelphic, or bicornuate uterus, blind hemivagina, and ipsilateral renal agenesis, and to consider the frequently unsatisfactory surgical approach. Methods Thirty-six women with double, didelphic, or bicornuate uterus, blind hemivagina, and ipsilateral renal agenesis were identified from clinical records for the period 1962 to 1992. We evaluated demographic data, disease, symptoms, correctness of therapeutic approach, and definitive treatment. Results Seventeen patients previously had undergone incomplete surgery in other hospitals and 19 were treated by us for the first time. Total hysterectomy was performed on two of the 36 women and hemihysterectomy and hemicolpectomy were performed on four. In the other 30, the vaginal septum was excised and marsupialization was done. The pregnancy rate in the 15 women wanting children was 87% and the live birth rate was 77%. Serial biopsy specimens were obtained from the lateral fornix after the excision of the septum in 13 of the 30 non-hysterectomized patients over 1–9 years and revealed progressively more extensive areas of squamous metaplasia of müllerian epithelium. In some isolated cases, papillary hyperplasia, mild dysplasia, and vaginal adenosis were found. At the end of follow-up, 16 patients still did not want children. Follow-up was possible in 34 cases. Conclusion Early accurate diagnosis after menarche followed by excision and marsupialization of the blind hemivagina offers complete relief of symptoms and preserves reproductive potential. Partial morphologic changes are evident but metabolic modifications comparable to those of the adjacent normal vagina have not yet been documented.

Gestrinone versus danazol in the treatment of endometriosis

Thirty-nine infertile patients with laparoscopic diagnosis of endometriosis were allocated randomly to treatment with gestrinone 2.5 mg twice weekly (20 patients) or danazol 600 mg/day (19 patients) for 6 months. If amenorrhea was not obtained after 1 month of treatment, the gestrinone dose was increased to 2.5 mg three times a week (7 patients) and the danazol dose to 800 mg/day (2 patients). One month after the end of the treatment, a repeat laparoscopy was performed only in the women who agreed (7 of the gestrinone treated group, 9 of the danazol group). All of the patients were followed for at least 12 months after the end of the treatment, during which time they attempted to conceive. There was a marked improvement of pain symptoms during the treatment in the patients of both groups. The repeat laparoscopy did not reveal significant differences between the two groups in the reduction of the disease extent. Eighteen months after treatment suspension, the cumulative pregnancy rate was 33% in the patients treated with gestrinone and 40% in those treated with danazol. Pain symptoms recurred during the follow-up in 57% of the gestrinone and 53% of the danazol group. The side effects were more frequent and severe with the danazol treatment, whereas those caused by gestrinone were mostly weight gain and acne. The results of this study suggest that gestrinone is as effective as danazol in the treatment of infertility associated with endometriosis and is better tolerated.

Buserelin versus danazol in the treatment of endometriosis-associated infertility

A total of 62 infertile women with a laparoscopic diagnosis of endometriosis were allocated randomly to two treatment groups, one of which (32 patients) received oral danazol 600 micrograms/day and the other (30 patients) received intranasal buserelin 1200 micrograms/day for 6 months. Suppression of serum levels of estradiol was greater with the gonadotropin-releasing hormone agonist treatment. Pain symptoms improved markedly during treatment in both groups. At the end of treatment a repeat laparoscopy was performed only in the patients who agreed to it (12 in the buserelin group and 13 in the danazol group), and it did not reveal significant differences in the effects of the two treatments on the endometriotic implants. All of the patients were followed up for at least 12 months, during which pregnancy was attempted. At 18 months the cumulative pregnancy rate was 48% in the patients treated with buserelin and 43% in those treated with danazol. Pain recurrence was observed in about half of the patients in each group 1 year after treatment suspension. The side effects were more frequent and more severe in the danazol-treated patients, whereas those given buserelin generally reported only symptoms of hypoestrogenism. The results of this study suggests that buserelin is at least as effective as danazol in the treatment of endometriosis when the outcome is considered in terms of restored fertility, and its side effects are less severe.

Reproductive and menstrual factors and risk of peritoneal and ovarian endometriosis.

OBJECTIVE Between 1987 and 1989 data were collected to evaluate risk factors for pelvic endometriosis. DESIGN A case-control study was conducted on 241 cases with laparoscopically or laparotomically confirmed peritoneal or ovarian endometriosis consecutively admitted to three teaching hospitals in Northern Italy. The control group consisted of 437 women admitted to hospitals for acute conditions covering similar catchment areas. RESULTS Compared with nulliparous women, the risk of endometriosis decreased with increasing number of births: the point estimates were 0.4 and 0.3, respectively, for those with one and two or more births (X2(1) trend = 50.3, P less than 0.001). No relation emerged with age at first birth and spontaneous miscarriages. Relative to women whose menarche occurred at age 11 or younger, the risk of endometriosis was slightly lower in those who experienced later menarche, but the trend in risk was not significant. Women with irregular menstrual cycles showed a lower frequency of the disease (relative risk, 0.3; 95% confidence interval, 0.2 to 0.5). The role of various factors was largely similar for different disease locations (ovary, peritoneum, and both) and indication for diagnostic surgery (sterility, pelvic pain, and other reasons). CONCLUSIONS This study found that parity and irregular/long menses lower the risk of endometriosis. These findings were similar in different subgroups of disease location and indication for surgery, giving strong evidence of the consistency of the general results.

Buserelin acetate versus expectant management in the treatment of infertility associated with minimal or mild endometriosis: A randomized clinical trial

OBJECTIVE We performed a randomized clinical trial to evaluate the efficacy of intranasal 400 micrograms buserelin three times daily for 6 months versus expectant management in the treatment of infertile women with pelvic endometriosis stage I or II of the revised American Fertility Society classification. STUDY DESIGN Seventy-one consecutive patients (mean age 32 years) were studied at the First Department of Obstetrics and Gynecology, University of Milan, and the Department of Obstetrics and Gynecology, Ospedali Riuniti, Bergamo, between February 1988 and June 1989. Thirty-five women were randomly allocated to buserelin treatment and 36 to expectant management. The baseline distribution of subjects for age, disease stage, and reproductive history was similar in the two groups. All patients were followed regularly; median follow-up was 17 months in the buserelin group and 18 months in the women given expectant management. If pregnancy did not occur within 12 months of randomization, cycles were monitored by ultrasonography and hormone measurements, and when abnormalities were detected clomiphene citrate and human chorionic gonadotropin were administered. RESULTS A total of 17 pregnancies were observed both in the buserelin-treated patients and in the expectant management group. The 1- and 2-year actuarial overall pregnancy rates were similar in the two groups, 30% and 61% in the former and 37% and 61% in the latter group, respectively. Spontaneous abortion occurred in five of the 17 pregnancies in the women treated with buserelin and in one of the 17 in those managed expectantly; this difference was, however, not statistically significant (chi 1(2) adjusted for disease stage and use of clomiphene citrate and human chorionic gonadotropin treatment = 3.01, p = 0.08). No fetal death or stillbirth was observed. CONCLUSIONS Our findings suggest that treatment with gonadotropin-releasing hormone agonists is unlikely to have a marked influence on the reproductive outcome of infertile women with minimal or mild endometriosis.

Reproductive performance of women with unicornuate uterus

The reproductive history of 19 women with a diagnosis of unicornuate uterus confirmed by laparoscopy or laparotomy is analyzed. The patients were followed for 2 to 10 years. One patient had a cavitary communicating rudimentary horn, four a cavitary noncommunicating rudimentary horn, seven a noncavitary rudimentary horn, and seven no rudimentary horn. Six of the patients presented with primary infertility. The other 13 women had a total of 29 pregnancies, 1 (3.4%) in a rudimentary horn determining rupture; abortions occurred in 17 (58.6%), premature labor in 3 (10.3%), and term births in 8 (27.6%), with a live birth rate of 38%. Of the 11 births, 6 (54.5%) were breech presentations, and 9 (81.8%) were cesarean sections. In five cases the rudimentary horn was removed, with associated salpingooophorectomy in three patients. Cervical cerclage was not performed in any of the patients.

Laparoscopy in the diagnosis of gynecologic chronic pelvic pain

Laparoscopy was performed on 126 women with undiagnosed chronic pelvic pain. Abnormalities were demonstrated in 62.7% of the cases. Endometriosis was present in 32.5% of the women. Laparoscopy is useful in the differential diagnosis of chronic pelvic pain and is indicated when symptoms persist for over 6 months.