Ilenia Cortesi

Endometriosis and pelvic pain: relation to disease stage and localization *

OBJECTIVESnTo determine whether prevalence and severity of pain symptoms are related to endometriosis stage and site, with particular reference to deep infiltrating vaginal lesions.nnnDESIGNnSystematic assessment of chronic pelvic pain symptoms.nnnSETTINGnUniversity hospital endometriosis center.nnnPATIENTSnA total of 244 consecutive symptomatic patients with endometriosis diagnosed at laparoscopy or laparotomy.nnnINTERVENTIONSnAssessment of dysmenorrhea and nonmenstrual pain by means of a 10-point linear analog scale, a 7-point multidimensional rating scale, and a 3-point verbal scale; evaluation of deep dyspareunia with the first and third systems only.nnnMAIN OUTCOME MEASURESnPrevalence and severity of pain symptoms in relation to endometriosis stage and site of lesions. Correlation between revised American Fertility Society score and symptoms severity, as well as between two pain scales to assess dysmenorrhea and nonmenstrual pain.nnnRESULTSnEighty-eight women had stage I and II disease and 156 had stage III and IV disease. Only ovarian endometriosis was present in 108 patients, only peritoneal implants were present in 37, combined ovarian and peritoneal lesions were present in 57, and histologically confirmed vaginal endometriosis was present in 42. The frequency and severity of deep dyspareunia and the frequency of dysmenorrhea were less in patients with only ovarian endometriosis than in those with lesions at other sites. Patients with vaginal endometriosis had a significantly increased risk of deep dyspareunia compared with those whose lesions were at other sites (odds ratio, 2.55; 95% confidence interval, 1.21 to 5.39). Stage per se, independent of lesion site, was not correlated with frequency and severity of dysmenorrhea and nonmenstrual pain. The severity of deep dyspareunia was related inversely to the endometriosis score (Spearman correlation coefficients for linear analog and verbal rating scales, respectively, -0.22 and -0.20). Kendall test by ranks revealed a correlation between linear analog and multidimensional pain scales in the rating of both dysmenorrhea and nonmenstrual pain (respectively, tau-b, 0.59 and tau-b, 0.68).nnnCONCLUSIONSnEndometriosis stage in the current classification was not related consistently to pain symptoms. The presence of vaginal lesions was associated frequently with severe deep dyspareunia. Dysmenorrhea and nonmenstrual pelvic pain were assessed with equal accuracy by a linear analog and a multidimensional scale.

Levonorgestrel-releasing intrauterine device versus hysteroscopic endometrial resection in the treatment of dysfunctional uterine bleeding

Objective To compare the effect of a levonorgestrel-releasing intrauterine device with that of endometrial resection on menstrual bleeding, patient satisfaction, and quality of life in menorrhagic women during 12 months of followup. Methods Seventy premenopausal women with dysfunctional uterine bleeding were enrolled in a prospective, open, parallel-group, controlled trial. They were randomized to either insertion of an intrauterine system releasing 20 μg/day of levonorgestrel (n = 35) or endometrial resection (n = 35). The women were evaluated at baseline, and thereafter, uterine bleeding was assessed monthly with a pictorial blood loss assessment chart. Clinical gynecologic examination was performed bimonthly, and the hematologic variables were measured at 6 and 12 months. On the latter occasion, the women were requested to rate the degree of satisfaction with the effect of their treatment and to complete the Short Form 36 General Health Survey questionnaire. Results Recurrent menorrhagia was observed at 12 months in four women in the intrauterine device group (including two with partial expulsion of the device) and in three women in the resection group. Compared with baseline values, at 1 year, the pictorial blood loss assessment chart score was reduced by 79% in the former group and by 89% in the latter. Amenorrhea or hypomenorrhea at 12 months was reported by 65% of the women with an intrauterine device compared with 71% who underwent endometrial resection. The degree of satisfaction with treatment was high in both groups, with 29 of 34 (85%) women being satisfied or very satisfied in the intrauterine device group versus 33 of 35 (94%) in the resection group. Health-related quality of life perception was not significantly different in the two treatment groups. Conclusion Somewhat less satisfactory results were obtained with a levonorgestrel-releasing intrauterine system compared with endometrial resection for dysfunctional uterine bleeding at 1 year of follow-up.

Progestins for symptomatic endometriosis: a critical analysis of the evidence

OBJECTIVEnTo obtain estimates of the effects of progestin treatment for pelvic pain associated with endometriosis.nnnDATA IDENTIFICATIONnInformation from studies published in the English-language literature between 1966 and 1996 was pooled. Articles were identified through hand and computerized searches using MEDLINE.nnnSTUDY SELECTIONnA total of 27 trials that were published in peer-reviewed journals were identified, and 13 of these were excluded from the analysis because of methodologic limitations. Nine of the remaining 14 studies were noncomparative (8 prospective and 1 retrospective), 1 was quasi-randomized, and 4 were true randomized controlled trials.nnnDATA EXTRACTION AND SYNTHESISnThe sample size was generally limited; the mean number of patients included was 26 in the noncomparative trials and 29 in the randomized controlled trials. The mean duration of treatment was 6 months. A total of 355 women had pain at entry. Considering all noncomparative studies, the pooled frequency of nonresponders at the end of treatment was 9% (18/203; 95% confidence interval [CI], 5.3% to 13.6%). The common odds ratio from the four randomized controlled trials comparing progestins with danazol or a GnRH agonist was 1.1 (95% CI, 0.4 to 3.1), suggesting equivalence in treatment effect. In the only double-blind, placebo-controlled trial, the frequency of nonresponders was not significantly different in the two arms. Only four studies assessed pain after drug withdrawal. The pooled frequency of pelvic pain at the end of follow-up was 50% (35/70; 95% CI, 37.8% to 62.2%). The overall crude conception rate after therapy among women who desired pregnancy was 44% (86/194; 95% CI, 37.2% to 51.6%). Side effects of limited clinical relevance were observed frequently.nnnCONCLUSION(S)nThe available data suggest that the efficacy of progestins for temporary relief of endometriosis-associated pelvic pain is good and comparable to that of other, less safe treatments.

Laparoscopy versus laparotomy in conservative surgical treatment for severe endometriosis.

OBJECTIVEnTo determine the outcome of laparoscopy compared with laparotomy in conservative surgical treatment for severe endometriosis.nnnDESIGNnComparison of nonrandomized historical surgical series.nnnSETTINGnTwo teaching hospitals and referral centers specializing in reparative and reconstructive surgery.nnnPATIENT(S)nA total of 216 patients operated for severe endometriosis during a 5-year period.nnnINTERVENTION(S)nConservative surgical treatment at laparoscopy (n = 67) or laparotomy (n = 149) with median follow-up of 24 months.nnnMAIN OUTCOME MEASURE(S)nCumulative probability of pregnancy in previously infertile patients (22 in the laparoscopy group and 70 in the laparotomy group) and cumulative probability of pain recurrence in subjects with moderate or severe symptoms before surgery (47 in the laparoscopy group and 108 in the laparotomy group).nnnRESULT(S)nThe 24-month cumulative probability of pregnancy according to the Kaplan-Meier method was 44.9% after laparoscopy and 62.7% after laparotomy. The 24-month cumulative probability of symptoms recurrence evaluated with a 0 to 3 point verbal rating scale was, respectively, 16.4% versus 20.3% for dysmenorrhea, 33.3% versus 15.4% for deep dyspareunia, and 25.0% versus 15.9% for nonmenstrual pain. The corresponding figures obtained with a 10-point linear analogue scale were 20.3% versus 24.7%, 28.6% versus 10.4%, and 17.5% versus 20.1%. No difference is statistically significant.nnnCONCLUSION(S)nLaparoscopy and laparotomy seem equally effective in the treatment of infertility and chronic pelvic pain associated with severe endometriosis. However, a trend was observed toward a higher pregnancy rate and lower dyspareunia recurrence rate after surgery for severe endometriosis performed at laparotomy compared with laparoscopy.

Depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol for long-term treatment of pelvic pain associated with endometriosis

OBJECTIVEnOur purpose was to evaluate the efficacy and safety of depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol in the long-term treatment of pelvic pain in women with endometriosis.nnnSTUDY DESIGNnEighty patients with endometriosis and moderate or severe pelvic pain were randomized to treatment for 1 year with intramuscular depot medroxyprogesterone acetate 150 mg every 3 months or a cyclic monophasic oral contraceptive (ethinyl estradiol 0.02 mg, desogestrel 0.15 mg) combined with oral danazol 50 mg a day for 21 days of each 28-day cycle. The women were asked to grade the degree of their satisfaction at the end of therapy. Variations in severity of symptoms during treatment were determined by a 10 cm visual analog and a 0- to 3-point verbal rating scale.nnnRESULTSnTwenty nine of 40 subjects (72.5%) in the depot medroxyprogesterone acetate group were satisfied after 1 year of therapy compared with 23 of 40 (57.5%) in the oral contraceptive plus danazol group (chi 2(1) = 1.37, p = 0.24, odds ratio 1.95, 95% confidence interval 0.76 to 4.97). A significant decrease was observed in all symptom scores in both study groups. At 1-year assessment dysmenorrhea was significantly greater in women allocated to oral contraceptive plus danazol.nnnCONCLUSIONnDepot medroxyprogesterone acetate seems to be an effective, safe, and convenient low-cost treatment for pelvic pain associated with endometriosis. However, women should be carefully counseled regarding menstrual changes and the potential prolonged delay in the return of ovulation.

Endometrial resection versus vaginal hysterectomy for menorrhagia: long-term clinical and quality-of-life outcomes.

OBJECTIVEnOur purpose was to compare patients satisfaction with the effect of treatment, health-related quality of life, psychologic status, and sexual functioning 2 years after endometrial resection or vaginal hysterectomy for menorrhagia.nnnSTUDY DESIGNnMenorrhagic women < or = 50 years old with a mobile uterus smaller than a 12-week pregnancy were enrolled in a randomized trial to compare endometrial resection and vaginal hysterectomy. Two years after surgery the women were requested to rate the degree of satisfaction with the effect of the operation and to complete the Short Form 36 general health survey questionnaire, the Hospital Anxiety and Depression Scale, and the revised Sabbatsberg Sexual Rating Scale.nnnRESULTSnForty-one subjects underwent endometrial resection and 44 underwent vaginal hysterectomy without major complications. Of the 77 women attending the 2-year follow-up visit, 33 of 38 (86.8%) in the endometrial resection arm were very satisfied or satisfied with the treatment compared with 37 of 39 (94.8%) of those in the hysterectomy arm. According to the Short Form 36 questionnaire, social functioning and vitality scores were significantly better in the hysterectomy group than in the resection group. Significantly lower Hospital Anxiety and Depression Scale anxiety scores were observed in the former than in the latter subjects. The Sabbatsberg Sexual Rating Scale scores were similar in the two groups.nnnCONCLUSIONSnIn patients requiring surgical treatment for menorrhagia vaginal hysterectomy appeared slightly more satisfying and offered a better health-related quality of life than did endometrial resection at 2-year follow-up. Hysterectomy did not adversely affect psychologic status and sexual functioning.

Bladder Detrusor Endometriosis: Clinical and Pathogenetic Implications

PURPOSEnWe examined the pathogenesis of vesical endometriosis, identified the diagnostic signs and defined a successful management strategy.nnnMATERIALS AND METHODSnThe records of 8 patients with bladder detrusor endometriosis were reviewed.nnnRESULTSnTwo distinct forms of the condition appear to exist, that is spontaneous and post-cesarean. In the former case the bladder lesion is a manifestation of a generalized pelvic disease, whereas after iatrogenic dissemination growth of ectopic endometrium is usually limited to the bladder wall. The catamenial nature of bladder symptoms (frequency, urgency, dysuria and tenesmus) was pathognomonic. Cystoscopy with biopsy was diagnostic in 3 cases. Ultrasonography revealed an endo-luminal vegetation and ruled out an anterior uterine leiomyoma, whereas magnetic resonance imaging did not add relevant information. Partial cystectomy appears to cure the urinary disturbances.nnnCONCLUSIONSnWe suggest a high index of suspicion of vesical endometriosis in all premenopausal women complaining of catamenial bladder symptoms with negative urine cultures.

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

STUDY OBJECTIVESnTo 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.nnnDESIGNnProspective, observational study.nnnSETTINGnAcademic department and tertiary care referral center for malformations of the female genital tract.nnnPATIENTSnTen women with complete septate uterus.nnnINTERVENTIONSnThe cervical portion of the septum was incised with Metzenbaum scissors and the corporeal portion with microscissors under hysteroscopic guidance.nnnMEASUREMENTS AND MAIN RESULTSnMean +/- 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.nnnCONCLUSIONSnSection 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.

Endometrial ablation with a vaporizing electrode in women with regular uterine cavity or submucous leiomyomas

To verify the technical feasibility and safety of endometrial ablation with a vaporizing electrode (Vaportrode), we performed operative hysteroscopy in a consecutive series of 40 women (mean ± SD age 45.3 ± 4.7 yrs) with established menorrhagia and uterine volume less than 12 weeks gestation. The results in 26 women with a regular uterine cavity were compared with those in 14 patients who had submucous myomas with less than 50% intramural extension. Surgery was undertaken after 2-month treatment with a depot gonadotropin-releasing hormone agonist. Pure cutting current was set at 200 W. Mean ± SD operating time was 8.6 ± 2.4 minutes in women with a regular cavity and 14.4 ± 5.2 in those with submucous myomas (mean difference 5.8 minutes, 95% CI 3.4-8.3). Corresponding values for distention fluid absorption were, respectively, 76 ± 103 and 227 ± 138 ml (mean difference 151 ml, 95% CI 73-229). A significant correlation was observed between operating time and distention fluid deficit (Spearman r = 0.47, p = 0.002). No complications occurred and all the procedures were performed as day surgery. After a mean follow-up of 4 months, no recurrence of menorrhagia was reported. Endometrial ablation with the Vaportrode is rapid, effective, and safe. Fluid deficit, although significantly greater in women with submucous myomas than in those with regular cavities, always remained within safety limits and below the usual values observed after resection with the wire loop.

Comparison of postoperative complications after Küstner and Pfannenstiel transverse suprapubic incisions

Abstract. We compared postoperative morbidity with the Küstner (n=53) and Pfannenstiel (n=131) incisions in a consecutive series of women undergoing surgery for benign gynecological conditions. The incidence of febrile morbidity (15.1% vs 23.7%, χ21=1.19, P=0.28) and wound infection (5.7% vs 9.2%, P=0.56, Fishers exact test) were higher in the Pfannenstiel then in the Küstner group, but neither difference was statistically significant. One suprafascial hematoma was observed after a Küstner incison compared with eight subfascial hematomas after a Pfannenstiel incision (1.9% vs 6.1%, P=0.45, Fishers exact test). The postoperative hospital stay was statistically significantly lower in the Küstner than in the Pfannenstiel group (6.3±1.4 vs 7.1±1.2 days, P<0.01, Students t test). The Küstner incision warrants further evaluation and usage.