Olga De Giorgi

Continuous use of an oral contraceptive for endometriosis-associated recurrent dysmenorrhea that does not respond to a cyclic pill regimen

OBJECTIVEnTo ascertain whether long-term reduction of pain is obtained by continuous administration of an oral contraceptive (OC) in women with endometriosis-associated recurrent dysmenorrhea that does not respond to cyclic OC use.nnnDESIGNnProspective, therapeutic, self-controlled clinical trial.nnnSETTINGnA tertiary care and referral center for patients with endometriosis.nnnPATIENT(S)nFifty women who underwent surgery for endometriosis in the previous year and experienced recurrent dysmenorrhea despite cyclic OC use.nnnINTERVENTION(S)nContinuous use of an OC containing ethinyl estradiol (0.02 mg) and desogestrel (0.15 mg) for 2 years.nnnMAIN OUTCOME MEASURE(S)nDysmenorrhea variation during cyclic and continuous OC use, evaluated with a 100-mm visual analog scale and a 0- to 3-point verbal rating scale, and degree of satisfaction with continuous OC treatment.nnnRESULT(S)nIn the study period, amenorrhea, spotting, and breakthrough bleeding were reported by 19 (38%), 18 (36%), and 13 (26%) women. The mean +/- SD number of >7-day bleeding episodes with consequent 7-day OC suspension was 5.5 +/- 2.1. The mean +/- SD dysmenorrhea visual analog scale and verbal rating scale scores were 75 +/- 13 and 2.4 +/- 0.5 at baseline and 31 +/- 17 and 0.7 +/- 0.6 at 2-year follow-up, respectively. Moderate or severe side effects were reported by 7/50 (14%) women. At final evaluation, 13 (26%) women were very satisfied, 27 (54%) were satisfied, 1 (2%) was uncertain, 8 (16%) were dissatisfied, and 1 (2%) was very dissatisfied.nnnCONCLUSION(S)nLong-term continuous OC use can be proposed to women with symptomatic endometriosis and menstruation-related pain symptoms.

Comparison of a levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study

Abstract Objective To determine whether the frequency and severity of dysmenorrhea are reduced in women with symptomatic endometriosis in whom a levonorgestrel-releasing intrauterine device (Lng-IUD) is inserted after operative laparoscopy compared with those treated with surgery only. Design Open-label, parallel-group, randomized, controlled trial. Setting A tertiary care and referral center for patients with endometriosis. Patient(s) Parous women with moderate or severe dysmenorrhea undergoing first-line operative laparoscopy for symptomatic endometriosis. Intervention(s) Randomization to immediate Lng-IUD insertion or expectant management after laparoscopic treatment of endometriotic lesions. Main outcome measure(s) Proportions of women with recurrence of moderate or severe dysmenorrhea in the two study groups 1 year after surgery and overall degree of satisfaction with treatment. Result(s) Moderate or severe dysmenorrhea recurred in 2 of 20 (10%) subjects in the postoperative Lng-IUD group and 9/20 (45%) in the surgery-only group. Thus, a medicated device inserted postoperatively will prevent the recurrence of moderate or severe dysmenorrhea in one out of three patients 1 year after surgery. A total of 15/20 (75%) women in the Lng-IUD group and 10/20 (50%) in the expectant management group were satisfied or very satisfied with the treatment received. Conclusion(s) Insertion of an Lng-IUD after laparoscopic surgery for symptomatic endometriosis significantly reduced the medium-term risk of recurrence of moderate or severe dysmenorrhea.

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.

Cyproterone acetate versus a continuous monophasic oral contraceptive in the treatment of recurrent pelvic pain after conservative surgery for symptomatic endometriosis

OBJECTIVEnTo evaluate the efficacy and safety of cyproterone acetate versus an oral contraceptive in the treatment of endometriosis-associated recurrent pelvic pain.nnnDESIGNnRandomized controlled trial.nnnSETTINGnAcademic center.nnnPATIENT(S)nNinety women with recurrent moderate or severe pelvic pain after conservative surgery for symptomatic endometriosis.nnnINTERVENTION(S)nSix months of continuous treatment with oral cyproterone acetate, 12.5 mg/d, or an oral contraceptive containing ethinyl estradiol, 0.02 mg, and desogestrel, 0.15 mg.nnnMAIN OUTCOME MEASURE(S)nDegree of satisfaction with therapy.nnnRESULT(S)nSix patients in the cyproterone acetate arm and nine in the oral contraceptive arm withdrew because of side effects (n = 9), treatment inefficacy (n = 4), or loss to follow-up (n = 2). At 6 months, dysmenorrhea, deep dyspareunia, and nonmenstrual pelvic pain scores were substantially reduced, and significant improvements were observed in health-related quality-of-life, psychiatric profile, and sexual satisfaction; no major between-group differences were seen. Subjective and metabolic side effects were limited. According to an intention-to-treat analysis, 33 of 45 (73%) of patients in the cyproterone acetate group and 30 of 45 (67%) in the oral contraceptive group were satisfied with the treatment received.nnnCONCLUSIONSnBoth cyproterone acetate and a continuous monophasic oral contraceptive were effective, safe, and inexpensive therapy for recurrent pain after conservative surgery for endometriosis.

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.

Hysteroscopic myomectomy: long-term effects on menstrual pattern and fertility

OBJECTIVEnTo determine the effects of hysteroscopic myomectomy on menorrhagia and infertility and the influence of intramural extension on surgical feasibility and long-term outcomes.nnnMETHODSnWe studied 108 women who had first-line hysteroscopic resection of submucous pedunculated (n = 54), sessile (n = 30), or intramural (n = 24) leiomyomas over 7 years at an academic department specializing in endoscopic surgery.nnnRESULTSnThe mean (+/- standard deviation) operating time and distension medium deficit were 18+/-7 minutes and 204+/-276 mL in the pedunculated lesion group, 23+/-9 minutes and 278+/-269 mL in the sessile lesion group, and 32+/-8 minutes and 335+/-272 mL in the intramural lesion group, respectively. More than one procedure was required to complete myoma removal in 14 (26%) of 54, eight (26%) of 30, and 12 (50%) of 24 subjects in the pedunculated, sessile, and intramural lesion groups, respectively. After a mean follow-up of 41 months, myomas recurred in 27 subjects, with a 3-year cumulative rate of 34%. Twenty women had recurrent menorrhagia, with a 3-year cumulative probability of 30%. The 3-year cumulative probability of conception was 49% in women with pedunculated lesions, 36% in those with sessile lesions, and 33% in those with intramural lesions. The study had 80% power to detect five- and three-fold increases in menorrhagia recurrence and conception rates, respectively, in the mainly intramural myoma group compared with the completely or mainly intracavitary myoma group.nnnCONCLUSIONnHysteroscopic resection of submucous myomas gives satisfactory menorrhagia control and limited recurrence, but the benefit for infertility was less impressive. Myoma intramural extension did not have a substantial influence on any of the long-term outcomes but affected operating time and the number of procedures needed for complete removal.

A levonorgestrel-releasing intrauterine system for the treatment of dysmenorrhea associated with endometriosis: a pilot study

OBJECTIVEnTo evaluate the efficacy and safety of an intrauterine system releasing 20 microg of levonorgestrel per 24 hours in the long-term treatment of recurrent dysmenorrhea in women already operated on conservatively for endometriosis.nnnDESIGNnA prospective noncomparative pilot study.nnnSETTINGnA tertiary care and referral academic center for patients with endometriosis.nnnPATIENT(S)nTwenty parous women with recurrent moderate or severe dysmenorrhea after conservative surgery for endometriosis who did not want further children.nnnINTERVENTION(S)nA levonorgestrel-releasing intrauterine system was inserted in each woman within 7 days of the start of a menstrual cycle.nnnMAIN OUTCOME MEASURE(S)nVariations in severity of dysmenorrhea during treatment according to a 100-mm visual analogue scale and a 0-3-point verbal rating scale, modification of a pictorial blood-loss assessment chart devised to evaluate the amount of menstrual flow, and degree of satisfaction after 12 months of therapy.nnnRESULT(S)nOne woman was lost to follow-up after achieving amenorrhea and expressing satisfaction, and 1 requested system removal because of weight gain and abdominal bloating. In another subject, the levonorgestrel intrauterine system was expelled 3 months after insertion. The menstrual patterns in the remaining 17 women were characterized by amenorrhea in 4 cases, hypomenorrhea or spotting in 8, and normal flow in 5. Baseline and 12-month follow-up mean +/- SD blood loss scores were 111+/-36 and 27+/-26, respectively. At the same time, mean +/- SD visual analogue and verbal rating scale scores dropped, respectively, from 76+/-12 to 34+/-23 points and from 2.5+/-0.5 to 1.2+/-0.5 points. Four women were very satisfied with treatment, 11 were satisfied, 2 were uncertain, and 3 were dissatisfied at 12-month follow-up.nnnCONCLUSION(S)nBecause of the amenorrhea or hypomenorrhea induced in most women, a levonorgestrel intrauterine system greatly reduced menstrual pain associated with endometriosis and achieved a high degree of patient satisfaction.

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.

Is cystic ovarian endometriosis an asymmetric disease

Objective To investigate whether asymmetry exists in the left‐ and right‐handed distribution of ovarian cystic lesions in a large series of women with endometriosis.

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.