Giulia Montanari

Long-term cyclic and continuous oral contraceptive therapy and endometrioma recurrence: a randomized controlled trial

OBJECTIVE To evaluate long-term cyclic and continuous administration of oral contraceptive pills (OCP) in preventing ovarian endometrioma recurrence after laparoscopic cystectomy. DESIGN Prospective, randomized, controlled trial. SETTING Tertiary care University Hospital. PATIENT(S) Two hundred thirty-nine women who underwent laparoscopic excision of ovarian endometriomas. INTERVENTION(S) Patients were divided randomly into three groups: nonusers receiving no therapy and cyclic and continuous users receiving low-dose, monophasic OCP for 24 months in cyclic or continuous administration, respectively. MAIN OUTCOME MEASURE(S) Endometrioma recurrence, size of recurrent endometrioma, and growth rate during at least 2 years follow-up evaluated by transvaginal ultrasonography. RESULT(S) The crude recurrence rate within 24 months was significantly lower in cyclic (14.7%) and continuous users (8.2%) compared with nonusers (29%). The recurrence-free survival was significantly lower in nonusers compared with cyclic and continuous users. The mean recurrent endometrioma diameter at first observation was significantly lower in cyclic (2.17 +/- 0.45 cm) and continuous users (1.71 +/- 0.19 cm) compared with nonusers (2.73 +/- 0.56 cm). The mean diameter increase every 6 months of follow-up was significantly reduced in cyclic users (0.31 +/- 0.18 cm) and continuous users (0.25 +/- 0.09 cm) versus nonusers (0.48 +/- 0.3 cm). No significant differences between cyclic users and continuous users in terms of endometrioma recurrence were demonstrated. CONCLUSION(S) Long-term cyclic and continuous postoperative use of OCP can effectively reduce and delay endometrioma recurrence.

Importance of Retroperitoneal Ureteric Evaluation in Cases of Deep Infiltrating Endometriosis

STUDY OBJECTIVE To discuss our clinical and surgical experience with 30 cases of ureteral endometriosis. DESIGN Retrospective analysis (Canadian Task Force classification II-3). SETTING Tertiary care university hospital. PATIENTS Records were assessed for all patients who underwent laparoscopic surgery for deep infiltrating endometriosis (DIE) from June 2002 through June 2006. Thirty patients were laparoscopically given a diagnosis that was histologically confirmed of ureteral involvement by endometriosis. INTERVENTIONS Laparoscopic retroperitoneal examination and management of ureteral endometriosis. MEASUREMENTS AND MAIN RESULTS Variables assessed were: preoperative findings (patient characteristics, clinical symptoms, preoperative workup), operative details (type and site of ureteral involvement, associated endometriotic lesions, type of intervention, intraoperative complications), and postoperative follow-up (short- and long-term outcomes). We recorded details of 30 patients with a median age of 33.33 years and a median body mass index of 21.96. Symptoms reported were: none in 20 (66.7%) of 30 patients, specific in 10 (33.3%) of 30, dysuria (30%), renal angle pain (10%), hematuria (3.3%), and hydroureteronephrosis (33.3%). Ureteral endometriosis was presumptively diagnosed before surgery in 40% of patients. Ureteric involvement was on the left side in 46.7%, on the right side in 26.7%, and bilaterally in 26.7%. It was extrinsic in 86.7% and intrinsic in 13.3%. It was associated with endometriosis of homolateral uterosacral ligament in all (100%) of 30, the bladder in 50%, rectovaginal septum in 80%, ovaries in 53.3%, and bowel in 36.7%. Laparoscopic intervention was: only ureterolysis in 73.3%, segmental ureteral resection and terminoterminal anastomosis in 16.7%, and segmental ureterectomy and ureterocystoneostomy in 10%. Early postoperative complications were: fever greater than 38 degrees C requiring medical therapy for 7 days in 7 patients and 1 patient had transient urinary retention requiring catheterization that resolved without further treatment. During a mean follow-up period of 14.6 months, endometriosis recurred in 3 patients with no evidence of ureteral reinvolvement. CONCLUSION Ureteral involvement is a silent, serious complication that must be suspected in all cases of DIE. Retroperitoneal laparoscopic isolation and inspection of both ureters helps to diagnose silent ureteral involvement. Conservative laparoscopic surgery provides a safe, feasible modality for management of ureteral endometriosis.

Conservative laparoscopic management of urinary tract endometriosis (UTE): surgical outcome and long-term follow-up

OBJECTIVE To evaluate surgical outcome and long-term follow-up of conservative laparoscopic management of urinary tract endometriosis (UTE). DESIGN Prospective study. SETTING Tertiary-care university hospital. PATIENT(S) Women with laparoscopic diagnosis and histologic confirmation of urinary bladder or ureteral endometriosis who agreed to undergo long-term follow-up after laparoscopic management. INTERVENTION(S) (1) Laparoscopic partial cystectomy for bladder endometriosis. (2) Uretric endometriosis laparoscopically managed by: uretrolysis only; segmental ureterectomy and terminoterminal anastomosis; or segmental ureterectomy and uretrocystoneostomy. MAIN OUTCOME MEASURE(S) Variables assessed were: preoperative findings, operative details (type and site of UTE, type of intervention, perioperative complications), and long-term follow-up (persistence/recurrence of preoperative urinary symptoms, if present, and anatomic relapse of the disease). RESULT(S) Mean operating time was 152.8+/-41.7 minutes. Mean drop in hemoglobin was 1.9+/-1.6 g/dL. Average hospital stay was 6 days. After surgery, 11 women had fever>38 degrees C and four presented transient urinary retention. During a follow-up period of 36 months, endometriosis recurred in eight patients with no evidence of bladder or ureteral reinvolvement, and there was a significant reduction in the mean score of dysuria and suprapubic pain maintained during the whole follow-up period. CONCLUSION(S) Results of long-term follow-up demonstrate significant reduction in preoperative symptoms with no anatomic relapse.

Women with deep infiltrating endometriosis: Sexual satisfaction, desire, orgasm, and pelvic problem interference with sex

INTRODUCTION Endometriosis is a chronic and progressive condition of women of reproductive age. It is strongly associated with a significant reduction of quality of life (QOL) and sexual function. AIMS This study aims to objectively evaluate sexual function in women with deep infiltrating endometriosis (DIE) and to study the impact of endometriosis symptoms and type of lesion on patients sexual function. METHODS This is a cross-sectional study in a tertiary care university hospital. It included 182 patients with preoperative clinical and ultrasound diagnosis of DIE who were referred to our center from 2008 to 2011. MAIN OUTCOME MEASURES A sexual activity questionnaire, the Sexual Health Outcomes in Women Questionnaire (SHOW-Q) was used to collect data pertaining to satisfaction, orgasm, desire, and pelvic problem interference with sex. Short Form 36 (SF-36) was used to evaluate QOL. Demographic and clinical characteristics were assessed: age, body mass index, parity, ethnicity, postsecondary education, employment, smoking, history of surgical treatment, and hormonal contraception. Patients were asked about pain symptoms (dysmenorrhea, dyspareunia, dyschezia, chronic pelvic pain, and dysuria) using a visual analog scale. RESULTS The mean values obtained on the different scales of the SHOW-Q showed poor sexual function (mean SHOW-Q total score 56.38 ± 22.74). Satisfaction was the dimension most affected (mean satisfaction score 55.66 ± 34.55), followed by orgasm (mean orgasm score 56.90 ± 33.77). We found a significant correlation between the SF-36 scores and the SHOW-Q scores (P < 0.0001). Sexual dysfunction and deterioration of QOL seem to be correlated. Analyzing the impact of symptoms and lesions on sexual function, we found that dyspareunia and vaginal DIE nodules significantly affect sexual activity (P < 0.05). CONCLUSION The results of this study demonstrated that women with DIE have a sexual function impairment, correlated with the overall well-being decrease. Moreover, the presence of dyspareunia and vaginal endometriotic lesions seems to be involved in sexual dysfunction.

What is the Impact on Sexual Function of Laparoscopic Treatment and Subsequent Combined Oral Contraceptive Therapy in Women with Deep Infiltrating Endometriosis

INTRODUCTION Deep infiltrating endometriosis (DIE) is a form of endometriosis in which the lesion penetrates for more than 5 mm under the peritoneal surface. It is a chronic disease which can impair womens sexual function. There is a growing body of evidence supporting combined surgical/medical treatment in the management of DIE. AIMS The aims of this article are to evaluate the impact of the laparoscopic full excision of endometriosis and postoperative combined oral contraceptives (COC) administration on sexual function in patients with DIE and to compare sexual function outcomes of women submitted to intestinal resection and nodule excision. METHODS It is a prospective cohort study in a tertiary care university hospital on 106 sexually active women, with histologically confirmed DIE, managed by laparoscopy and subsequent COC therapy for 6 months. Patients filled preoperatively and 6-month postoperatively a quality of sexual life questionnaire, the Sexual Health Outcomes in Women Questionnaire (SHOW-Q) and they ranked their symptom intensity using a 10-point visual analogue scale (VAS). MAIN OUTCOME MEASURES Sexual function was measured through the SHOW-Q scores and pain symptoms through VAS scores. Intraoperative details, type of intervention and perioperative complications were noted. RESULTS Six months after surgery and postoperative COC treatment, a significant improvement was observed in the SHOW-Q domains of pelvic problem interference, sexual satisfaction and desire (P<0.05). Laparoscopic management of DIE did not change significantly the orgasm area of the sexual functioning (P=0.7). No significant difference was found in SHOW-Q scores between patients submitted to intestinal resection and patients submitted to intestinal nodule excision (P>0.05). CONCLUSIONS Sexual desire, satisfaction with sex and pelvic problem interference with intercourse are significantly improved after 6 months from laparoscopic excision of DIE combined with postoperative COC therapy. No difference in sexual outcomes was detected between patients submitted to intestinal resection and nodule excision.

Do women with endometriosis have to worry about sex

OBJECTIVE(S) Sexual function is negatively influenced by endometriosis and women with endometriosis show less sexual and partnership satisfaction compared to patients with other gynaecological disorders. This study aims to compare sexual function between patients with deep infiltrating endometriosis (DIE) and healthy women using Sexual Health Outcomes in Women Questionnaire (SHOW-Q). STUDY DESIGN Case-control study including 182 patients with histological diagnosis of DIE and 182 healthy women, who referred to our tertiary care university hospital from 2010 to 2012. SHOW-Q was used to collect data concerning satisfaction, orgasm, desire and pelvic problem interference with sex. The un-paired t-test was performed to compare the means of a continuous variable between groups when the data were normally distributed; otherwise the Mann-Whitney test was used to check t-test results. Pearsons χ(2) test and Z-test for proportions - independent groups were performed to investigate the difference among grouping variables. RESULTS As described in a previous study, the prevalence of sexual dysfunction in women with endometriosis is around 61% and in women with other gynaecological disorders is 35%. Assuming 5% significance and 95% power, 106 women would be required for the study. Every area of sexual function investigated through the SHOW-Q questionnaire (satisfaction, desire, orgasm and pelvic problem interference) was significantly impaired compared to healthy women. Among patients with DIE, 58% (105/182) reported that pelvic pain severely affected sexual function, while only 1% (2/182) of healthy women (p<0.0001). Moreover, sexual desire was absent or less than one or two times per month in 45% (82/182) of women with DIE compared to 14% (26/182) of healthy women (p<0.0001). CONCLUSION(S) DIE severely affects sexual function. Endometriosis is a global disease, which affects patients physically, psychologically and sexually. The potential sexual consequences of this disease need to be considered.

Prevalence of adenomyosis in women undergoing surgery for endometriosis

OBJECTIVE(S) To evaluate the prevalence of adenomyosis in patients undergoing surgery for endometriosis. STUDY DESIGN Retrospective study including 1618 women with preoperative clinical and ultrasound diagnosis of endometriosis. As preoperative assessment, all patients underwent ultrasound to assess endometriosis and all features associated with adenomyosis (heterogeneous myometrial echotexture, globular-appearing uterus, asymmetrical thickness of anteroposterior wall of the myometrium, subendometrial myometrial cysts, subendometrial echogenic linear striations or poor definition of the endometrial-myometrial junction). RESULTS Adenomyosis was present in 353/1618 (21.8%) women included in the study. Multivariate analysis showed that the prevalence of adenomyosis was significantly associated with deep infiltrating endometriosis, parity, dysmenorrhea intensity and womens age (P<0.0001). CONCLUSION(S) Adenomyosis is a common condition but its aetiology and natural history are still unknown. Our experience showed a 21.8% of prevalence of adenomyosis in patients affected by endometriosis and its association with parous women, increasing age, dysmenorrhea intensity and with the presence of deep infiltrating endometriosis.

A new oral contraceptive regimen for endometriosis management: preliminary experience with 24/4-day drospirenone/ethinilestradiol 3 mg/20 mcg

We report our preliminary experience with the use of a low-dose oral contraceptive containing Drospirenone/Ethinylestradiol 3 mg/20 mcg, both in cyclic and continuous regimen for endometriosis management. A total of 93 women were retrospectively included: 52 were treated by medical therapy (exclusive combined oral contraceptives (COC)-users), while 41 were submitted to surgery followed by postoperative therapy (postoperative COC-users). A clinical examination was performed at baseline and at 6-months follow-up. Presence and intensity of endometriosis-related symptoms were assessed by a visual analogue scale. Presence and dimension of endometriotic lesions were evaluated by transvaginal ultrasonography. Adverse effects and tolerability were analysed. In exclusive COC-users, significant reductions in dysmenorrhoea and dyspareunia scores and in endometrioma mean diameter were observed at follow-up. In postoperative COC-users, anatomical and symptom recurrence rates at follow-up were 4.9% and 17%, respectively. The most frequent adverse effects were spotting and headache. No difference between cyclic and continuous regimen in terms of symptom relief, lesion progression and tolerability was observed. From our preliminary experience, Drospirenone/Ethinylestradiol 3 mg/20 mcg seems to be promising in endometriosis management.

Performance of peripheral (serum and molecular) blood markers for diagnosis of endometriosis.

PurposeTo quantify the mRNA levels of MMP-3, MMP-9, VEGF and Survivin in peripheral blood and the serum levels of CA-125 and Ca19-9 in women with and without endometriosis and to investigate the performance of these markers to differentiate between deep and ovarian endometriosis.MethodsA case control study enrolled a series of 60 patients. Twenty controls have been matched with 20 cases of ovarian and 20 cases of deep endometriosis. Univariable and multivariable performance of serum CA125 and CA19-9, mRNA for Survivin, MMP9, MMP3 and VEGF genes have been evaluated by means of ROC curves and logistic regression, respectively.ResultsNo difference in markers’ concentration was detected between ovarian and deep endometriosis. In comparison with controls, serum CA125 and CA19 yielded the better sensitivity followed by mRNA for Survivin gene (81.5, 51.9 and 7.5% at 10% false positive rate, respectively). Multivariable estimated odds of endometriosis yielded a sensitivity of 87% at the same false positive rate.ConclusionsA combination of serum and molecular markers could allow a better diagnosis of endometriosis.

Does colorectal endometriosis alter intestinal functions? A prospective manometric and questionnaire-based study.

OBJECTIVE To objectively evaluate using anorectal manometry whether endometriotic nodules influence intestinal function and to reveal subjective intestinal dysfunctions in patients with rectosigmoid deep infiltrating endometriosis. DESIGN Prospective study. SETTING Tertiary care university hospital. PATIENT(S) Patients (n = 25) with a preoperative diagnosis of rectosigmoid endometriosis. INTERVENTION(S) Patients underwent anorectal manometry; after that, they filled a questionnaire about defecatory functions and ranked their pain symptoms. MAIN OUTCOME MEASURE(S) The parameters studied were resting pressure, maximum squeezing pressure, pushing, rectoanal inhibitory reflex, and rectal sensibility. We analyzed the responses to the defecatory function questionnaire and the scored the endometriosis pain symptoms using a Visual Analogue Scale. RESULT(S) No alterations of the rectoanal inhibitory reflex were found. Hypertone of the internal anal sphincter was found in 20 of 25 patients. Almost half of the patients had an increase of the threshold of desire to defecate, and 7 patients had a reduction of the anal sphincter squeeze pressure. According to the responses to the defecatory function questionnaire, incomplete evacuation was the most common symptom. CONCLUSION(S) We did not find marked motility or sensitive dysfunctions at the anorectal manometry, whereas subjectively patients reported some defecatory disorders. We revealed the presence of hypertone of the internal anal sphincter in most of the patients. CLINICAL TRIAL REGISTRATION NUMBER 74/2010/O/Sper.