Lucia Lazzeri

Ultrasound mapping system for the surgical management of deep infiltrating endometriosis

OBJECTIVE To assess the accuracy of transvaginal sonography (TVS) in defining size and location of deep infiltrating endometriosis (DIE) with laparoscopic/histologic confirmation. DESIGN Prospective observational study. SETTING University hospital. PATIENT(S) One hundred four women with suspected DIE on the basis of TVS. INTERVENTION(S) Patients with DIE underwent TVS evaluation before laparoscopic surgery. An accurate mapping of the extent of the disease was recorded during TVS and at laparoscopy. This new mapping system was developed to assess the extent of endometriosis by measuring the size and depth of the lesions at the various pelvic locations. MAIN OUTCOME MEASURE(S) Surgical and histologic confirmation of the ultrasonographic data to evaluate the presence and location of DIE and creation of a new mapping methodology for detecting DIE by TVS. RESULT(S) Depending on the different location of the lesions, the accuracy of TVS ranged from 76%-97%. The lowest sensitivity (59%) and accuracy (76%) were obtained for TVS in the diagnosis of vaginal endometriosis, whereas the greatest accuracy (97%) was shown in detecting bladder lesions and Douglas obliteration. CONCLUSION(S) This new ultrasound mapping system is accurate for detecting the extent of DIE and may be useful for preoperative planning and intraoperative management of symptomatic patients with DIE.

Preoperative and postoperative clinical and transvaginal ultrasound findings of adenomyosis in patients with deep infiltrating endometriosis

Objectives: Deep infiltrating endometriosis (DIE) represents the most complex form of endometriosis and its treatment is still challenging. The coexistence of DIE with other appearances of endometriosis stimulates new studies to improve the preoperative diagnosis. Adenomyosis is a clinical form that shares several symptoms with DIE. The present study investigated the possible presence of adenomyosis in a group of women with DIE and its impact on pre- and postoperative symptoms. Materials and Methods: A group of women (n = 121) undergoing laparoscopic treatment for DIE were enrolled. Clinical and ultrasound evaluations were performed as preoperative assessment. The ultrasonographical appearances of DIE and of adenomyosis were recorded by 2-dimensional ultrasound. The following symptoms were considered: dysmenorrhea, dyspareunia, abnormal uterine bleeding, bowel, and urinary symptoms. Pain was evaluated by the visual analog scale system and menstrual bleeding was assessed by the use of the pictorial blood assessment chart. In a subgroup of women (n = 55), a follow-up evaluation (3-6 months after surgery) was done. Results: A relevant number of patients with DIE showed adenomyosis (n = 59; 48.7%); in this group, dysmenorrhea (P = .0019), dyspareunia (P = .0004), and abnormal uterine bleeding (P < .001) were statistically higher than that in the group with only DIE. After surgery, painful symptoms improved in the whole group but remained significantly higher (P < .001) in the group with adenomyosis. Conclusions: Deep infiltrating endometriosis is frequently associated with adenomyosis, significantly affecting pre- and postoperative symptoms and thus influencing the follow-up management.

Endometriosis in Italy: From cost estimates to new medical treatment

Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, which induced a chronic inflammatory reaction. The data collected from Italy showed that around 3 million women are affected by endoemtriosis and the condition was predominantly found in women of reproductive age (50% of women were in the 29–39 age range), only 25% of women were asymptomatic. The associated symptoms can create an impact in general physical, mental, and social well-being. Endometriosis is associated with severe dysmenorrhea, deep dyspareunia, chronic pelvic pain, ovulation pain, cyclical, or perimenstrual symptoms, with or without abnormal bleeding, infertility, and chronic fatigue. The annual cost for hospital admission can be estimated to be in a total around 54 million euros. The average time for right diagnosis is around 9 years still today and it follows a long and expensive diagnostic search. Therapies can be useful to relieve and sometimes solve the symptoms, encourage fertility, eliminate endometrial lesions, and restore the anatomy of the pelvis. For medical therapy, several different preparations (oral contraceptives, progestogenics, gestrinone, danazol, and GnRHa) and new options (GnRH antagonists, aromatase inhibitors, estrogen receptor beta agoinist, progesterone receptor modulators, angiogenesis inhibitors, and COX-2 selective inhibitors) are available.

Efficacy of vaginal danazol treatment in women with menorrhagia during fertile age

OBJECTIVE To evaluate the clinical efficacy and patient satisfaction of danazol delivered vaginally as treatment for young women with menorrhagia. DESIGN Prospective study. SETTING University of Siena, Siena, Italy. PATIENT(S) Women with menorrhagia (n = 55; age range 25-35 years) after ultrasound and hysteroscopy. INTERVENTION(S) Low-dose danazol (200 mg/day) was daily administered by vaginal route for 6 months. MAIN OUTCOME MEASURE(S) Before and every month during the treatment women were requested: 1) to keep a diary of menstrual bleeding and to rate blood loss on a visual analog scale from 0 (no blood loss) to 10 (gushing-type bleeding); 2) to record side effects and their satisfaction with the therapy. Transvaginal ultrasound, blood count, serum chemistries, and serum concentration of LH, FSH, E(2), TSH, FT(3), FT(4), and PRL were evaluated before and after 6 months. RESULT(S) The severity of blood loss was significantly reduced in all of the women after 2 months of treatment. Uterine volume was significantly reduced, and hematocrit, hemoglobin, and red blood cell count increased in all of the women after 6 months. The medical treatment did not affect hormonal parameters, and menstrual cycle remained unaffected; few local vaginal adverse effects were recorded. CONCLUSION(S) Vaginal danazol resulted in effective medical treatment in young women with menorrhagia, and, because of a lack of significant adverse effects, it may be proposed as an alternative treatment.

Transvaginal sonographic features of diffuse adenomyosis in 18–30‐year‐old nulligravid women without endometriosis: association with symptoms

To investigate whether there are sonographic features of diffuse adenomyosis in 18–30‐year‐old nulligravid women without endometriosis and to examine their association with symptoms of dysmenorrhea and abnormal uterine bleeding.

How to Manage Bowel Endometriosis: The ETIC Approach

A panel of experts in the field of endometriosis expressed their opinions on management options in a 35-year-old patient desiring pregnancy with a history of previous surgery for endometrioma and bowel obstruction symptoms. Many questions that this paradigmatic patient may pose to the clinician are addressed, and various clinical scenarios are discussed. A decision algorithm derived from this discussion is proposed as well.

Adenomyosis by transvaginal ultrasonographic features in nulligravid women without endometriosis aged 18–30 years: correlation with symptoms

To investigate whether there are sonographic features of diffuse adenomyosis in 18–30‐year‐old nulligravid women without endometriosis and to examine their association with symptoms of dysmenorrhea and abnormal uterine bleeding.

Serum anti-Müllerian hormone, inhibin B, and total inhibin levels in women with hypothalamic amenorrhea and anorexia nervosa

Objective. To evaluate whether neuroendocrine forms of secondary amenorrhea (hypothalamic nervosa (HA) and anorexia nervosa (AN)) affect serum anti-Müllerian hormone (AMH), inhibin B, and total inhibin levels. Methods. Amenorrheic women (n = 82) (aged between 16 and 35 years old) according to diagnosed with neuroendocrine forms of amenorrhea: HA (n = 64), AN (n = 18), and healthy women (n = 41) (control group) were enrolled. Serum AMH, inhibin B, and total inhibin levels were measured by specific ELISA. Results. No statistically significant difference of AMH serum levels between women with HA, AN, and control group was observed. Serum inhibin B and total inhibin levels in women with HA (p < 0.0001), AN (p < 0.05) resulted significantly lower than in control healthy women. Conclusion. The present data showed that neuroendocrine forms of amenorrhea are associated with an impaired inhibin secretion while not AMH. These data indirectly support that AMH is an excellent marker of ovarian reserve and its secretion is not influenced by the hypothalamic-ovarian axis activity.

Nonsurgical Alternatives for Uterine Fibroids

Uterine leiomyomata are the direct cause of a significant health-care burden for women, their families, and society as a whole. Because of the long experience with the mode of treatment, surgical myomectomy remains the gold standard for treating reproductive-age women; however, in the recent years, the wide evolution of less invasive approaches led to a change in the options used by the clinician to treat symptomatic fibroids. Minimally invasive procedures such as uterine artery embolization (UAE) are increasingly used to treat symptomatic fibroids. Other alternative treatments are becoming more diffuse, such as magnetic resonance-guided high-frequency focused ultrasound surgery (MRgFUS), cryomyolysis, vaginal occlusion, and laparoscopic closure of the uterine arteries. Both advantages and limitations of these techniques under development must be taken into account, but this wider range of choices is being increasingly considered for a tailored treatment. This article aims to enable health-care providers with the tools to provide the latest evidence-based care in the minimally invasive or noninvasive management of this common problem.

Expression of microtubule associated protein 2 and synaptophysin in endometrium: high levels in deep infiltrating endometriosis lesions

OBJECTIVE To assess whether healthy endometrium, eutopic endometrium, and endometriotic lesions express nerve growth factor (NGF), microtubule-associated protein 2 (MAP-2), and synaptophysin (SYP). DESIGN Molecular study in tissue extracts. SETTING University hospital. PATIENT(S) A group of women (n = 70), divided as [1] healthy controls (n = 30) and [2] with endometriosis (n = 40), was included. INTERVENTION(S) From the healthy control group an endometrial specimen was collected by hysteroscopy (proliferative phase, n = 16; secretive phase, n = 14). Endometriotic and endometrial specimens were collected from women undergoing laparoscopic surgery for endometriosis, endometrioma (OMA) (n = 20), or deep infiltrating endometriosis (DIE) (n = 20). MAIN OUTCOME MEASURE(S) To assess expression of NGF, MAP-2, and SYP messenger RNA (mRNA) levels in endometrium and in endometriosis by quantitative reverse transcription polymerase chain reaction (qRT-PCR) and protein localization by immunofluorescence. Cultures of human endometrial stromal cells were used to evaluate the effect of tumor necrosis factor (TNF)-α on NGF and SYP. RESULT(S) Endometrial tissue from control expressed mRNA for NGF, MAP-2, and SYP, without any difference between proliferative and secretive phase. The DIE and OMA lesions showed the highest NGF mRNA expression, significantly higher than in eutopic endometrium and control. In DIE lesions SYP mRNA expression was higher than in OMA or in eutopic endometrium or controls. Immunofluorescence analysis of NGF, MAP-2, and SYP showed a slightly more intense positive signal in endometriotic lesions. Exposure to TNF-α increased NGF and SYP mRNA expression in endometrial culture cells. CONCLUSION(S) The present study revealed the presence of two selected neuronal markers, MAP-2 and SYP mRNAs and protein expression, in eutopic endometrium and in endometriotic lesions.