Ronald E. Batt

Retrocervical, Rectovaginal Pouch, and Rectovaginal Septum Endometriosis

The paper by Anaf et al in this issue has a title using a global area, the rectovaginal (RV) pouch of Douglas, rather than the specific retrocervical location as the site of endometriosis. Although this is an anatomically correct title, it can suggest both rectal and vaginal involvement with endometriosis. The authors clarify that nodules were removed only from the vaginal portion of the RV pouch and not from the rectum itself. Use of the global term can create confusion similar to that noted in 1917 and 1989 articles that described RV septum involvement where this was not present. The 1917 article has illustrations and the 1989 article a magnetic resonance image (MRI) of retrocervical RV pouch endometriosis with minimal or no involvement of the RV septum. The illustrations and MRI suggest lengthening of the RV septum due to RV pouch contraction. Lengthening of the RV septum has also been associated with pregnancy. The RV pouch covers part of the vagina and rectum, and its base is the upper limit of the RV septum. The RV pouch is not the RV septum. Retroperitoneal endometriosis and posterior vaginal fornix endometriosis are behind the RV pouch, not within it. The degree of surgical treatment by Anaf et al is similar to that described for cul-de-sac endometriosis and retrocervical endometriosis. Retrocervical may be a more descriptive term for describing RV pouch, retroperitoneal, and vaginal fornix endometriosis behind or beneath the cervix with no rectal involvement. Rectovaginal is used when both vaginal and rectal areas of the pouch are involved and may include involvement of the RV septum. These distinctions are

Life-style factors and female infertility.

We summarize the epidemiologic literature on the effect of life‐style factors such as cigarette smoking, alcohol and caffeine consumption, physical exercise, body mass index, and drug use on female infertility. We identified relevant papers through MEDLINE, Index Medicus, and a manual review of reference lists. Risk factors that affect the risk of primary tubal infertility and that were corroborated in two or more studies include use of intrauterine devices (especially the Dalkon Shield) and cigarette smoking. We identified extremes in body size as a risk factor for primary ovulatory infertility. Cocaine, marijuana and alcohol use, exercise, caffeine consumption, and ever‐use of thyroid medications were possible risk factors for various subtypes of primary infertility. Few risk factors have been assessed or identified for secondary infertility or other less common subtypes, such as cervical or endometriosis‐related infertility.

Endometriosis and Body Fat Distribution

Objective: To examine the association of body fat distribution with risk of endometriosis in an effort to determine whether a specific somatotype is related to the disease. Methods: We conducted a case‐control study of 88 laparoscopically confirmed cases of endometriosis, identified in a specialty gynecologic practice in western New York, and 88 age‐matched friend controls. Data were collected by standardized personal interview, and body measurements were taken in a standardized fashion by one interviewer. Risk of endometriosis associated with body fat distribution, as expressed by waist‐to‐hip and waist‐to‐thigh ratios, was assessed using logistic regression. Results: For women under 30 years of age (45 cases, 46 controls), endometriosis was inversely related to both waist‐to‐hip ratio (odds ratio 6.18, 95% confidence interval [CI] 2.01‐19.01) and waist‐to‐thigh ratio (odds ratio 3.64, 95% CI 1.23‐10.78). This effect was not evident among women aged 30 years and older (43 cases, 42 controls). Conclusion: Our results suggest a specific somatotype with a predominance of peripheral body fat among women with endometriosis. This finding may provide information useful in both the diagnosis and understanding of the disease etiology. (Obstet Gynecol 1993;82:545‐9)

Pathogenesis of a parauterine uterus-like mass: developmentally misplaced müllerian tissue—müllerianosis

We suggest the theory of m€ullerianosis—developmentally misplaced m€ullerian tissue—offers a more powerful explanation for the pathogenesis for this parauterine uterus-like mass. In 2007, we defined m€ullerianosis by clinical-pathologic criteria as a heterotopic organoid structure of embryonic origin, a choristoma composed of m€ullerian rests—normal endometrium, normal endosalpingeal tissue, and normal endocervical tissue— incorporated singly or in combination within other normal organs during organogenesis (2). Subsequently, Signorile et al. (3) demonstrated the presence of ectopic endometrium in four human fetuses, empirical evidence supporting the theory of m€ullerianosis.

A case-series—Peritoneal pockets and endometriosis: Rudimentary duplications of the Müllerian system*

Abstract A study of 4 adolescent and 50 adult females with pelvic peritoneal pockets who presented with pelvic pain or infertility is reviewed. Histologic evidence of endometriosis was demonstrated in 60% of 54 patients with peritoneal pockets in the pouch of Douglas, in 71% with posterior broad ligament pockets, and in 80% with combined lesions. Thirty-three percent (18/54) had coexisting congenital anomalies of the primary mullerian and/or metanephric systems. A broad surface of mullerian tissue may form on the genital ridge. Rotation and fusion of the primary mullerian ducts to form the fallopian tubes, uterus, and upper vagina may result in the incorporation of mullerian tissue into the pouch of Douglas and the broad ligaments. After birth, this secondary mullerian tissue is thought to atrophy leaving peritoneal pockets with mullerian remnants. The dormant remnants could then be stimulated by ovarian hormones at menarche causing pelvic pain and infertility.

Health and fertility outcomes among women surgically treated for endometriosis

STUDY OBJECTIVE To assess health and fertility status among women after surgical treatment of endometriosis. DESIGN Prospective study. SETTING Community-based gynecologic specialty practice. PATIENTS Two hundred ninety women with newly diagnosed endometriosis. MEASUREMENTS AND MAIN RESULTS Medical records of all women were abstracted at baseline; self-administered questionnaires were used to collect follow-up data. Most women (68-79%) reported some or great improvement in symptomology after surgical treatment. One hundred twenty-four (53%) of 232 women reported one or more pregnancies, two-thirds of which resulted in live births. Secondary sex ratios were below 1 (range 0.92-0.50), reflecting a female excess. Logistic regression analysis identified previous live birth as the only significant predictor of pregnancy after surgery; advancing maternal age significantly decreased the likelihood of a live birth. CONCLUSIONS Overall, these women reported improvement in symptoms at follow-up. Operative and clinical findings were not significant predictors of pregnancy likelihood. Prior live birth conferred more than a twofold increase in pregnancy likelihood, whereas advancing age decreased the likelihood. Reasons for reversed sex ratios are unknown but warrant further study.

Postmenarchal development of chylous ascites in acrocephalosyndactyly with congenital lymphatic dysplasia

Background Acrocephalosyndactyly is a syndrome characterized by congenital malformation of the skull with craniosynostosis, midface hypoplasia, and symmetrical webbed fusion of the fingers and toes. We describe a possible pathophysiologic mechanism for chylous ascites that developed several months after menarche in a woman with acrocephalosyndactyly and congenital lymphatic dysplasia. Case A 25-year-old nulligravid woman with acrocephalosyndactyly, at 18 months after menarche, developed persistent abdominal distension at age 18 years. Laparoscopy at age 25 years revealed chylous ascites with marked chronic peritoneal inflammation, and lymphatic dysplasia with lymphocysts. With hormone manipulation, the chylous ascites fluctuated. Conclusion After menarche in a woman with acrocephalosyndactyly, ovarian steroid hormones might have increased lymph production and hydrostatic pressure, causing rupture of congenitally dysplastic lymph vessels resulting in chylous ascites.

COMMUNICATION AND DOCUMENTATION BEFORE AND AFTER LAPAROSCOPIC SURGERY

Increasingly, sanctions by Offices of Professional Medical Conduct, functioning at state level, and malpractice suits are being used to discipline physicians. A system of documentation and communication, practiced successfully for more than 30 years, can reduce the risk of such actions. (J Am Assoc Gynecol Laparosc 6(4):379-381, 1999)

Explication and Defense of Sampson’s Theory of Pathogenesis

In May 1927, at the 52nd annual meeting of the American Gynecological Society at Hot Springs, Virginia, Sampson stated: “At the meeting of the American Gynecological Society in 1921, the writer presented a paper1 on perforating hemorrhagic cysts of the ovary and their relation to pelvic adenomas of endometrial type…In view of the theories which have arisen to explain the origin of the peritoneal endometriosis associated with these cysts, the following quotation from that paper may be of interest.”2 “The question naturally arises: in what way do the contents of the cyst or ovary cause the development of these adenomas? Is it due to some specific irritant present in the cyst contents which stimulates the peritoneal endothelium to a metaplasia with the development of endometrial tissue typical both in structure and function? Some may assert that dormant endometrial epithelium may be present in the tissues soiled by the contents of the cyst and this is stimulated to further growth. It seems to me that the conditions found in many of these specimens are analogous to the implantation of ovarian papilloma or cancer on the peritoneal surfaces of the pelvis from the rupture of an ovarian tumor containing these growths.”3

Sampson’s Theory of Implantation Endometriosis

From a cursory examination of the literature, one might conclude that research and authorship on adenomyomas passed seamlessly and directly from Cullen to Sampson in 1921; Cullen’s last contribution appearing in Volume two and Sampson’s first article in Volume three of the Archives of Surgery.1 Such was not the case. Unlike the clear and seamless continuity from von Recklinghausen to Cullen, the transfer of authority from Cullen to Sampson was mediated and complicated. Cullen remained the undisputed authority on uterine adenomyomas, but not of extrauterine adenomyomas. In the sense that Sampson postulated a novel theory of pathogenesis to explain the many extrauterine adenomyomas described by Cullen – and in that sense only – there was continuity: mutual interest in the same subject, but the torch had not been passed as it had from von Recklinghausen to Cullen. In every other sense, the transition was marked by discontinuity.