Letizia Zannoni

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.

A prospective blinded comparison of the accuracy of transvaginal sonography and frozen section in the assessment of myometrial invasion in endometrial cancer

OBJECTIVE To compare the accuracy of preoperative transvaginal sonography (TVS) and intraoperative frozen section (FS) in the assessment of myometrial invasion of endometrial carcinoma, having the definitive histological examination as gold standard. METHODS 155 consecutive women (mean age 63 years, range 32-88) diagnosed as having endometrial carcinoma were prospectively evaluated at TVS in order to preoperatively stage the disease. All the patients subsequently underwent complete surgical staging including total abdominal hysterectomy, bilateral oophorectomy, pelvic and lumboaortic lymphadenectomy. After removal of the uterus, intraoperative FS was performed by pathologists with special interest in gynaecologic oncology in a predefined, standardized manner. Sensitivity, specificity, positive and negative predictive values were calculated for both modalities as regards neoplastic invasion of the myometrium. RESULTS Overall, 131 women (84.5%) had an endometrioid adenocarcinoma, 8 (5.2%) an adenosquamos carcinoma, 7 (4.5%) a serous papillary carcinoma, 4 (2.6%) a clear cell carcinoma, 3 (1.9%) a mixed type carcinoma, 1 (0.6%) a carcinosarcoma, and 1 (0.6%) a mesodermal mixed malignant tumor. Sensitivity, specificity, positive and negative predictive values and accuracy for TVS in the evaluation of myometrial infiltration were: 75%, 89%, 86%, 79% and 81%. Corresponding features for FS were: 92%, 92%, 89%, 94% and 92%. The diagnostic performance of FS was higher than that of TVS (Cohens K value: 0.841; p<0.0005). CONCLUSION Intraoperative FS performed better than preoperative TVS in the assessment of myometrial invasion by endometrial cancer. Despite being time consuming, FS can be regarded as a useful modality in order to decide whether to perform lymphadenectomy in cases with poor visualization of the endometrium at TVS and when TVS gives inconclusive results.

Intra- and interobserver agreement with regard to describing adnexal masses using International Ovarian Tumor Analysis terminology: reproducibility study involving seven observers.

To estimate intraobserver repeatability and interobserver agreement in assessing the presence of papillary projections in adnexal masses and in classifying adnexal masses using the International Ovarian Tumor Analysis terminology for ultrasound examiners with different levels of experience. We also aimed to identify ultrasound findings that cause confusion and might be interpreted differently by different observers, and to determine if repeatability and agreement change after consensus has been reached on how to interpret ‘problematic’ ultrasound images.

Question mark form of uterus: a simple sonographic sign associated with the presence of adenomyosis.

Adenomyosis as the presence of ectopic endometrial glands and stroma within the myometrium is an elusive condition that is challenging to diagnose due to the similarity between its clinical symptoms and ultrasound characteristics and those of other frequent benign conditions such as leiomyomatosis1. Over recent years, transvaginal sonography (TVS) has been recommended as an appropriate tool for visualization of adenomyosis, with a sensitivity of 65–81% and a specificity of 65–100%2. We performed a prospective study between January 2012 and January 2014 including 50 symptomatic fertile women who were scheduled to undergo elective hysterectomy because of symptoms of endometriosis/adenomyosis. Adenomyosis was diagnosed on TVS, in accordance with previous studies3,4, in the presence of one or more of the following criteria: heterogeneous myometrium, irregular cystic areas, hypoechoic linear striations, asymmetry of uterine walls and poor definition of the endometrial–myometrial junctional zone (JZ). Moreover, a novel sign, which we called ‘question mark Figure 1 Transvaginal ultrasound image and representative diagram showing the question mark form of the uterus as a marker for adenomyosis.

Dysmenorrhea, Absenteeism from School, and Symptoms Suspicious for Endometriosis in Adolescents

STUDY OBJECTIVE To quantify in adolescents the prevalence of dysmenorrhea and other symptoms found to be suggestive of future diagnosis of endometriosis, in particular their impact on monthly absenteeism from school/work, activity impairment, and sexual life and to quantify the awareness of endometriosis in adolescents. DESIGN Cross-sectional study. SETTING Academic institution. PATIENTS Adolescents (n = 250) aged 14-20 years referring to 3 family Counseling services. INTERVENTIONS Participants completed an anonymous questionnaire. MAIN OUTCOME MEASURES Prevalence of dysmenorrhea and absenteeism from school/work during menses. Other outcomes were impairment of daily activities, dyspareunia, and awareness of endometriosis as a pathologic condition. RESULTS 68% (170/250) of the participants complain of dysmenorrhea, 12% (30/250) lose days of school/work monthly because of dysmenorrhea, 13% (33/250) complain of intermenstrual pain which limits daily activities, 27% (56/208) of the adolescents who are sexually active complain of dyspareunia, 82% (203/250) have never heard about endometriosis and 80% (200/250) would like to know more about it. A significant association was found between severe dysmenorrhea, absenteeism from school/work, and basic level of education. Absence from school/work during menses showed an adjusted odds ratio for severe dysmenorrhea about 28 times greater than those who did not declare absenteeism (95%CI 7.898-98.920, P<.000). CONCLUSIONS The rates of dysmenorrhea and school absenteeism caused by dysmenorrhea are high. According to recent studies these patients are at higher risk of further development of endometriosis, whereas the knowledge of the disease is low among the adolescents investigated, so those involved with adolescents both in the health profession and particularly in schools and Family Counseling Services should be educated about endometriosis and its symptoms to reduce the significant lag time between symptoms and diagnosis.

Urodynamic evaluation and anorectal manometry pre- and post-operative bowel shaving surgical procedure for posterior deep infiltrating endometriosis: a pilot study.

STUDY OBJECTIVE To analyze bowel and urinary function in patients with posterior deep infiltrating endometriosis (DIE) >30 mm in largest diameter at transvaginal ultrasound before and after surgical nerve-sparing excision. DESIGN Prospective observational study (Canadian Task Force classification III). SETTING Tertiary care university hospital in Bologna, Italy. PATIENTS Twenty-five patients with posterior DIE were included in the study between June 2011 and December 2012. Patients did not receive hormone therapy for at least 3 months before and 6 months after surgery. INTERVENTIONS Patients underwent urodynamic studies and anorectal manometry before and after nerve-sparing laparoscopic excision of the posterior DIE nodule. MEASUREMENTS AND MAIN RESULTS Intestinal and urinary function was evaluated in patients with bulky posterior DIE using urodynamic and anorectal manometry. Results of urodynamic studies and anorectal manometry were similar before and after nerve-sparing surgical excision of the posterior DIE nodule. Urodynamic studies demonstrated a high prevalence of voiding dysfunction, whereas anorectal manometry showed no reduction in rectoanal inhibitory reflex and hypertone of the internal anal sphincter. CONCLUSIONS Patients with posterior DIE >30 mm in greatest diameter demonstrate preoperative dysfunction at urodynamic study and anorectal manometry, probably due to DIE per se. The nerve-sparing surgical approach seems not to influence the motility or sensory capacity of the bladder and the rectosigmoid colon.

Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series

STUDY QUESTION In women with deeply infiltrating endometriosis (DIE) what is the prevalence of involvement of endometriotic tissue and fibrosis in ureteral endometriosis (UE), as assessed by histological staining? SUMMARY ANSWER In women with DIE, ureteral involvement is more often due to endometriotic tissue rather than fibrosis. WHAT IS KNOWN ALREADY In the current literature, histological evaluation of ureteral endometriosis is mainly based on the degree of wall infiltration by endometriosis instead of the tissue composition. A few studies reported ill-defined and contradictory histological data on the tissue composition of UE. STUDY DESIGN, SIZE, DURATION Retrospective observational study based on clinical records of women affected by DIE, laparoscopically treated for UE at a tertiary referral center, between January 2010 and March 2013. All cases of ureteral nodule excision or ureterectomy with histological examination of the specimens were included. Exclusion criteria were other identified causes of hydroureteronephrosis, medical therapy for a period of at least 3 months before surgery and previous surgery for DIE. PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 77 patients were included in the study and among them seven (9%) presented with bilateral ureteral involvement, giving a total of 84 cases of UE available for analysis. All patients had stage IV endometriosis. According, respectively, to the presence of endometrial glands and/or stroma cells or of fibrotic tissue only, the endometriotic UE and fibrotic UE groups were compared with regard to hydroureteronephrosis at pre-operative urinary tract computerized tomography scan, type of surgical procedure performed to treat UE (nodule removal or ureterectomy), association with other locations of the disease and post-operative complications (ureteral fistula or stenosis). MAIN RESULTS AND THE ROLE OF CHANCE For the 84 cases of UE, 65 (77%) and 19 (23%), respectively, showed endometriotic tissue and fibrotic tissue only. Presence of hydroureteronephrosis and endometriotic pattern of UE showed a significant association [endometriotic UE 44/65 (68%) versus fibrotic UE 8/19 (42%); P = 0.04]. Fibrotic pattern of UE and presence of concomitant recto-vaginal endometriosis showed a significant association [endometriotic group: 29/65 (45%) versus fibrotic group 18/19 (95%); P < 0.001]. LIMITATIONS, REASONS FOR CAUTION The retrospective and monocentric (tertiary referral center) study design. WIDER IMPLICATIONS OF THE FINDINGS Besides the distinction between extrinsic and intrinsic UE based on the degree of wall infiltration by endometriosis, a new classification according to the histological pattern of UE could be useful for clinicians, both in the diagnostic and therapeutic fields. STUDY FUNDING/COMPETING INTERESTS None.

PLAC4 and β‐HCG mRNA levels are not altered in the maternal circulation of pregnancies with trisomy 21

β‐Human chorionic gonadotropin (HCG) and pregnancy‐associated plasma protein (PAPP‐A) are placentally produced proteins whose levels are altered in pregnancies with trisomy 21. PLAC4 is located on chromosome 21 and its expression is restricted to the placenta. Here we investigated whether the levels of β‐HCG‐, PAPP‐A‐ and PLAC4 mRNA could be able to discriminate pregnancies whose fetus is affected by trisomy 21.

Endometriosis in Adolescence: Practical Rules for an Earlier Diagnosis.

Dysmenorrhea, cyclic pelvic pain, and acyclic pelvic pain are common in adolescent girls, and at least 10% of these girls are at risk for subsequent development of endometriosis. In this article we highlight practical tips for the management of dysmenorrhea and chronic pelvic pain and how to diagnose endometriosis as early as possible and detect patients at risk for developing the disease in the future. We suggest five practical rules for managing adolescents with dysmenorrhea and chronic pelvic pain: (1) Never underestimate the pain; (2) Always consider endometriosis as a possible cause of severe cyclic pain; (3) Obtain a detailed and accurate history before performing clinical evaluation and pelvic sonography; (4) Treat the pain with hormonal therapies (combined oral contraceptives or progestogen-only pill) and analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs); and (5) Plan frequent follow-up visits to re-evaluate the patient. [Pediatr Ann. 2016;45(9):e332-e335.].

Intra- and inter-observer reproducibility of assessment of Doppler ultrasound findings in adnexal masses.

To estimate intra‐ and interobserver reproducibility and reliability of assessment of the color content in adnexal masses at color/power Doppler ultrasound examination for observers with different levels of experience, and to determine if they change after a consensus meeting.