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Problems related to endometriosis in modern gynecology
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The introduction of the ENZIAN Score was indicated to classify especially the retroperitoneal endometriosis. Analog to oncological classifications four levels and three axis for localisation of the endometriosis were used. The ENZIAN Score was planned as a standalone extension of the well known rAFS Score (revised American Fertility and Sterility Score). With respect to the rAFS Score only intraperitoneal endometriosis is classified and therefore this system has no proper clinical evidence. The ENZIAN Score was investigated in a retrospective analysis of our population with bowel endometriosis, who underwent laparoscopic bowel resection. As we pointed out, there was good clinical evidence of the ENZIAN Score.
Endometriosis is one of the most frequent, benign, proliferative diseases of the woman. The therapy concentrates on three problems: 1. Pain (mainly menstrual cycle dependent, but also menstrual cycle independent, bladder and bowel discomfort), 2. fertility disturbances (decreased conception rate and increased abortion rate), 3. impact on organ or organ function (i. e. ureter stenosis, bowel stenosis, bladder wall infiltration). Since endometriosis is a progressive disease with a high recurrence rate and during the time of ovarian function new lesions can develop, therefore, the medicinal therapy has a particular importance. For successful treatment early diagnosis of endometriosis is important. For treatment surgical procedures are available which should aim to remove all visible endometriotic lesions and if pregnancy is desired all operative procedures should be organand fertility-preserving. Type and extend of operation depend upon the individual findings. For medicinal treatment a number of drugs are available: 1. Estrogen/progestogen combination (pill) if possible as "long"-cycle, 2. progestogens continuously with the aim to accomplish amenorrhea, in order to obtain the optimal clinical effect, 3. GnRH-agonists, which are most effective to obtain quiescence of the ovaries and by this to reduce endometriosis, but lead by this to symptoms which can be alleviated by so called "add-back" therapy. This also avoids bone density loss. One has to consider, that medicinal therapy leads at most to a regression of endometriosis. After the end of treatment (operative or medicinal) one has to realize that after one or several years recurrence and/or new endometriotic lesions can be encountered. Therefore, the operative and medicinal control of endometriosis has to follow an individual long-term therapy concept. A number of further substances are at present time experimentally under clinical investigation.
The diagnostic laparoscopy is the gold standard today to stage pelvic endometriosis and to prove it by biopsy and histology. Other diseases of the pelvic organs can be seen or excluded by differential diagnosis. Laparoscopic treatment of peritoneal implants is the treatment of choice, which is proven for pain and infertility with prospective randomised studies.
The idea of quality improvement in the field of endometriosis has arrived in Europe. Different institutions and groups are working intensively towards the same goal using different and in some cases also identical approaches. The establishment of specialized endometriosis centres and the comprehensive qualification of physicians and medical staff along with greater research efforts belong to this range of measures, which also includes the training and informing of the patients as well as the raising of awareness among health politicians, cost-bearing institutions, and industry. Given scarce resources, the focusing of the existing national and international commitment is foreseeable and necessary. It remains to be seen whether this could lead to the consistent foundation of uniform national endometriosis groups as a basis for a European umbrella society. However, this is a goal which is worth striving for.
This chapter deals primarily with a variety of nonneoplastic and neoplastic lesions that are characterized by müllerian differentiation on histologic examination but a distribution that is predominantly external to structures derived from the miillerian ducts. These lesions typically occur in the pelvis and lower abdomen, involving the peritoneum, the subjacent tissues (including retroperitoneum), and lymph nodes. Their importance to the pathologist, therefore, includes their differentiation on microscopic examination from metastatic tumor.
To elucidate some biological characteristics of peritoneal endometriosis.
A recently advanced stereographic computer technology was applied for the investigation of the three-dimensional (3-D) architectures of peritoneal endometriosis.
University Hospital of Gynecology.
Biopsies were taken from 42 women with peritoneal endometriosis. Twenty-six of them were in the luteal phase. Seventeen of them received Zoladex (ICI, Cambridge, United Kingdom) for 12 weeks before biopsy.
Two different main types could be identified according to the presence or absence of ramifications. The apparently multifocal occurrence (in 2-D) of glandular epithelium was not confirmed by the 3-D study that showed that all epithelial glands are interconnected by luminal structures in each peritoneal lesion. Stereometric study suggests a stronger effect of gonadotropin-releasing hormone agonist therapy on the stroma than on the epithelium.
The study evaluated the 3-D architectures of peritoneal endometriosis and identified two principal types of peritoneal endometriosis.
The peritoneum covering the pelvic viscera is usually smooth and glistening. Defects in the pelvic peritoneum are usually presumed to be acquired. Allen and Masters described such a clinical syndrome, the anatomic cornerstone of which was laceration(s) of uterine supports with resultant defect(s) in the broad and/or uterosacral ligaments. This diagnosis has been made more often recently on the basis of laparoscopic findings alone. Twenty-five cases of pelvic peritoneal defects were documented in a series of 635 consecutive diagnostic laparoscopies done primarily for pelvic pain. None fit the criteria of the Allen-Masters syndrome. Sixty-eight percent had associated endometriosis. It is suggested that pelvic peritoneal defects may be causally related to endometriosis, the disease either attacking presumably previously altered peritoneal surfaces or causing peritoneal scarring, duplication, and reduplication secondary to the cyclic insults of the ectopic endometrium and thereby producing the appearance of traumatic lacerations. Further, it is suggested that when such defects are noted at laparoscopy, the presence of other associated pathologic abnormalities, including endometriosis, should be investigated.
To explore the hypothesis that endometriosis is a disease not just because it exists but because it is functionally active.
Qualitative research analyzing the morphologic appearances of endometriosis and the clinical effect of medical therapies.
Analysis of the appearances of symptomatic endometriosis demonstrates that the ectopic endometriumlike tissue mimics eutopic endometrium but with loss of polarization. Ectopic implants resembling superficial endometrium are hemorrhagic and associated with adhesion and pseudocyst or endometrioma formation. Ectopic implants resembling basal or junction zone endometrium are associated with nodular adenomyotic lesions in the posterior fornix and pelvic supportive structures. They are characterized by smooth muscle hyperplasia and T-lymphocyte aggregates.
Medical therapy has been shown to be very efficient in reducing pelvic pain as soon as amenorrhea is created and maintained. Regression, but not elimination, of the implant is obtained by medical therapy. Clinical data support the hypothesis that the efficacy of medical therapy is largely achieved by preventing cyclic bleeding in the implants.
To assess whether infertile women with minimal or mild endometriosis have lower fecundity than women with unexplained infertility.
Prospective cohort study.
Twenty-three infertility clinics across Canada.
Three hundred thirty-one infertile women aged 20-39 years.
Diagnostic laparoscopy for infertility. Infertile women with minimal or mild endometriosis (n = 168) were compared with women with unexplained infertility (n = 263). Both groups were managed expectantly. The women were followed up for 36 weeks after the laparoscopy or, for those who became pregnant, for up to 20 weeks of the pregnancy.
Fecundity refers to the probability of becoming pregnant in the first 36 weeks after laparoscopy and carrying the pregnancy for > or = 20 weeks. The fecundity rate is the number of pregnancies per 100 person-months.
Fecundity was 18.2% in infertile women with minimal or mild endometriosis and 23.7% in women without endometriosis (log-rank test). The fecundity rate was 2.52 per 100 person-months in women with endometriosis and 3.48 per 100 person-months in women with unexplained infertility. The crude and adjusted fecundity rate ratios were 0.72 and 0.83 (95% confidence interval = 0.53-1.32), respectively.
The fecundity of infertile women with minimal or mild endometriosis is not significantly lower than that of women with unexplained infertility.
The preponderance of recent data suggests that endometriosis does not adversely affect in-vitro fertilization pregnancy rates. However, many studies demonstrate impaired oocyte quality, decreased fertilization, and compromised implantation rates. Such findings give insight into the mechanisms by which endometriosis may impact on fertility, and provide clues as how to focus assisted reproductive technologies in order to overcome these deficiencies. Specifically, extended downregulation protocols, ample use of gonadotropins for ovarian stimulation, and conservative management of endometriomas have all been suggested as means to optimize in-vitro fertilization outcomes for women with endometriosis.
We report the case of a 30-year-old patient who underwent a segmental ureteral resection with ureteroureterostomy because of the presence of a left ureterohydronephrosis caused by an intrinsic ureteral endometriotic lesion. Preoperatively, the patient received a 3 months course of GNRH agonists. The serum estradiol level was at 12 pg/ml at the moment of surgery. Histology and immunohistochemistry performed on the resected specimen showed the presence of numerous large haemorrhagic endometriotic foci containing very high levels of alpha-estrogen and progesterone nuclear receptors, a high Ki-67 labeling index and a strong positivity for EGF-receptor. This is the first report of immunohistochemical study performed on ureteral endometriosis preoperatively treated with GNRH agonists. Because hormonal treatments are often prescribed in the treatment of ureteral endometriosis, clinicians should be aware of the possibility of persisting very active and proliferative ureteral endometriotic lesions even under treatment with GNRH agonists and very low levels of circulating estradiol.
Endometriosis represents a common and important clinical problem of women of childbearing age. It is a disabling disorder manifesting with pain and infertility. The exact pathogenesis of the disease remains unclear, despite the different theories that have been formulated. The literature on endometriosis is extensive, but often in regard to classic endometrioma. It is surprising that, to the best of our knowledge, the many radiologic features of extraovarian endometriosis have not been well documented thus far. Although ultrasound (US) remains the imaging modality of choice in the radiologic evaluation of female patients with pelvic pain, the role of magnetic resonance imaging (MRI) in the evaluation of abdominal pain is expanding. In the young patient, MRI may be performed if a gynecologic disorder is not suspected at first, especially if US findings are equivocal or the abnormality extends beyond the field of view of the sonographic probe. Moreover, MRI is useful whenever further characterization of pelvic disorder is required. In fact, many causes of pelvic disorders and of endometriosis in particular demonstrate characteristic MRI findings. For these reasons, in this work we describe the protean US and MRI appearances of endometrial foci as encountered in daily experience.