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Endometriosis

Endometriosis is a common medical condition affecting an estimated 89 million women of reproductive age around the world. In endometriosis, the tissue that lines the uterus (the endometrium, from endo, "inside", and metra, "womb") is found to be growing outside the uterus, on or in other areas of the body. Normally, the endometrium is shed each month during the menstrual cycle; however, in endometriosis, the misplaced endometrium is usually unable to exit the body. The endometriotic tissues still detach and bleed, but the result is far different: internal bleeding, degenerated blood and tissue shedding, inflammation of the surrounding areas, pain, and formation of scar tissue may result. In addition, depending on the location of the growths, interference with the normal function of the bowel, bladder, small intestines and other organs within the pelvic cavity can occur. In very rare cases, endometriosis has also been found in the skin, the lungs, the diaphragm, and even the brain.

Current Research

For current research articles click - here

Symptoms

A major symptom of endometriosis is pain, mostly in the lower abdomen, lower back, and pelvic area. The amount of pain a woman feels is not necessarily related to the extent or stage (1 through 4) of endometriosis. Some women will have little or no pain despite having extensive endometriosis affecting large areas or endometriosis with scarring. On the other hand, women may have severe pain even though they have only a few small areas of endometriosis.

Symptoms of endometriosis can include (but are not limited to):

Painful, sometimes disabling menstrual cramps (dysmenorrhea); pain may get worse over time (progressive pain)
Chronic pain (typically lower back pain and pelvic pain, also abdominal)
Painful intercourse (dyspareunia)
Painful bowel movements or painful urination (dysuria)
Heavy menstrual periods (menorrhagia)
Nausea and vomiting
Premenstrual or intermenstrual spotting (bleeding between periods)
Infertility and subfertility. Endometriosis may lead to fallopian tube obstruction. Even without this, there may be difficulty conceiving. In some women, subfertility is the sole symptom, and the endometriosis is only discovered after fertility investigations.

In addition, women who are diagnosed with endometriosis may have gastrointestinal symptoms that may mimic irritable bowel syndrome, as well as fatigue.

Patients who rupture an endometriotic cyst may present with an acute abdomen as a medical emergency. Endometriotic cysts in the thoracic cavity may cause some form of thoracic endometriosis syndrome, most often catamenial pneumothorax.

Epidemiology

Endometriosis can affect any woman of reproductive age, from premenarche to postmenopause, regardless of her race, ethnicity or whether or not she has children. Endometriosis often persists after menopause. In less common cases, girls may have endometriosis before they even reach menarche.

Current estimates place the number of women with endometriosis between 5% and 20% of women of reproductive age. About 30% to 40% of women with endometriosis are infertile, making it one of the leading causes of infertility. However, endometriosis-related infertility is often treated successfully with surgical destruction of the disease. Some women do not find out that they have endometriosis until they have trouble getting pregnant. While the presence of extensive endometriosis distorts pelvic anatomy and thus explains infertility, the relationship between early or mild endometriosis and infertility is less clear. The relationship between endometriosis and infertility is an active area of research.

Early endometriosis typically occurs on the surfaces of organs in the pelvic and intraabdominal areas. Health care providers may call areas of endometriosis by different names, such as implants, lesions, or nodules. Larger lesions may be seen within the ovaries as endometriomas or chocolate cysts (They are termed chocolate because they contain a thick brownish fluid, mostly old blood). Endometriosis may trigger inflammatory responses leading to scar formation and adhesions. Most endometriosis is found on structures in the pelvic cavity:

Ovaries
Fallopian tubes
The back of the uterus and the posterior culdesac
The front of the uterus and the anterior culdesac
Uterine ligaments such as the broad or round ligament of the uterus
Intestines, particularly the appendix
Urinary bladder

Endometriosis may spread to the cervix and vagina or to sites of a surgical abdominal incision. In extremely rare cases, endometriosis areas can grow in the lungs or other parts of the body.

Surgically, endometriosis can be staged I-IV (Revised Classification of the American Society of Reproductive Medicine).

Causes

While the exact cause of endometriosis remains unknown, many theories have been presented to better understand and explain its development. These concepts do not necessarily exclude each other.

Endometriosis is a condition caused by excess estrogen created each month in the female body, and is seen primarily during the reproductive years. In experimental models, excess estrogen is necessary to induce or maintain endometriosis. Medical therapy is often aimed at lowering estrogen levels to control the disease. It is hypothesized that excess estrogen levels may be measured by a female taking her morning temperature (with a thermometer showing a tenth decimal) at the same time each day for a month or two. To learn more about taking your waking temperature, please see the book: "Taking Charge of Your Fertility" by Toni Weschler, MPH. A normal woman's body temperature varies from 98.5 to 97.5 degrees Fahrenheit (36.9 to 36.3 degrees Celsius), however it is hypothesized that someone with endometriosis may see temperatures of 98.5 to 97.0 °F (36.9 to 36.1 °C). The lower temperatures signify the estrogen phase of a normal female's cycle, therefore it is logical that women with excessively lower body temperatures, may have an excess of estrogen, thus endometriosis. Research is needed to determine the reliability of using waking temperatures to diagnose endometriosis and its severity. Additionally, the current research into Aromatase, an estrogen-synthesizing enzyme produced by the implants themselves, has provided evidence as to why and how the disease persists after menopause and hysterectomy.
"Retrograde menstruation", by which some of the menstrual debris from the period flows into the pelvis, may play an important role (John A. Sampson). While most women may have some retrograde menstrual flow, typically their immune system is able to clear the debris and prevents implantation and growth of cells from this occurrence. However, in some patients, endometrial tissue transplanted by retrograde menstruation is able to implant and establish itself as endometriosis. Factors that might cause the tissue to grow in some women, but not in others, need to be studied, and some of the possible causes below may provide some explanation, i.e. hereditary factors, toxins, or a compromised immune system. It can be argued that the uninterrupted occurrence of regular menstruation over decades month after month is a modern phenomenon, as in the past women had more frequent menstrual rest due to pregnancy or lactation.
A competing theory suggests that endometriosis does not represent transplanted endometrium but starts de novo from local stem cells. This process has been referred to as coelomic metaplasia. Triggers of various kind (including menses, toxins, or immune factors) may be necessary to start this process.
Hereditary factors play a role. It is well recognized that daughters or sisters of patients with endometriosis are at higher risk to develop endometriosis themselves. A recent study (2005) published in the American Journal of Human Genetics found a link between endometriosis and chromosome 10q26. One study found that, in female siblings of patients with endometriosis the relative risk of endometriosis is 5.7:1 versus a control population.
It is accepted that in specific patients endometriosis can spread directly. Thus endometriosis has been found in abdominal incisional scars after surgery for endometriosis.
On rare occasions endometriosis may be transplanted by blood or by the lymphatic system into peripheral organs (i.e. lungs, brain).
Recent research is focusing on the immune system that may not be able to cope with the cyclic onslaught of retrograde menstrual fluid. In this context there is interest to study relationship to autoimmune disease, allergy reactions, and the impact of toxins.

Another area of research is the search for endometriosis markers. These markers are substances made by or in response to endometriosis that health care providers can measure in the blood, urine, or daily waking temperature. If markers are found, health care providers could diagnose endometriosis by testing a woman's blood, urine, or daily waking temperature which might reduce the need for surgery. CA125 is known to be elevated in many patients with endometriosis, but not specifically indicative of endometriosis.

Diagnosis

A history and a physical examination can in many patients lead the physician to suspect the diagnosis.

Use of imaging tests may identify larger endometriotic areas, such as nodules or endometriotic cysts. The two most common imaging tests are ultrasound and magnetic resonance imaging (MRI). Normal results on these tests do not eliminate the possibility of endometriosis - areas of endometriosis are often too small to be seen by these tests.

The only sure way to confirm an endometriosis diagnosis is by laparoscopy; also known as bandaid or keyhole surgery. The diagnosis is based on the characteristic appearance of the disease, if necessary corroborated by a biopsy. Laparoscopy also allows for surgical treatment of endometriosis.

Generally endometriosis-directed drug therapy (other than the oral contraceptive pill) is utilized after a confirmed surgical diagnosis of endometriosis.

Cause of Pain

The way endometriosis causes pain is the topic of much research. Because many women with endometriosis feel pain during or related to their periods and may spill further menstrual flow into the pelvis with each menstruation, some researchers are trying to reduce menstrual events in patients with endometriosis.

Endometrial tissue reacts to hormonal stimulation and may "bleed" at time of menstruation. It accumulates locally, causes swelling, and triggers inflammatory responses with activation of cytokines. It is thought that this process may lead to pain perception.

Endometriosis is thought to be an auto-immune condition and if the immune system is compromised with a food intolerance then removing that food from the diet, can with some people, have an effect. Common intolerances in people with endometriosis are wheat and dairy.

Treatments

Currently, there is no cure for endometriosis, though in some patients menopause (natural or surgical) will abate the process. Nevertheless, a hysterectomy and/or removal of the ovaries will not guarantee that the endometriosis areas and/or the symptoms of endometriosis will not come back. Conservative treatments usually try to address pain or infertility issues. Medical herbal treatments can be sometimes be effective in controlling the disease.

The treatments for endometriosis pain include:

NSAIDs and other pain medication: They often work quite well as they not only reduce pain but also menstrual flow. They are commonly used in conjunction with other therapy. For more severe cases narcotic prescription drugs may have to be used.
Gonadotropin Releasing Hormone (GnRH) Agonist: These agents work by increasing the levels of GnRH. Consistent stimulation of the GnRH receptors results in downregulation. This causes a decrease in FSH and LH, thereby decreasing estrogen and progesterone levels.
It is suggested but unproven that pregnancy and childbirth can stop endometriosis.
Hormone suppression therapy: This approach tries to reduce or eliminate menstrual flow and estrogen support. Typically, it needs to be done for several months or even years.
- Progesterone or Progestins: Progesterone counteracts estrogen and inhibits the growth of the endometrium. Such therapy can reduce or eliminate menstruation in a controlled and reversible fashion. Progestins are chemical variants of natural progesterone.
- Avoiding products with xenoestrogens, which have a similar effect to naturally produced estrogen and can increase growth of the endometrium.
- Continuous birth control pills consists of the use of birth control pills without the use of placebo pills. This eliminates monthly bleeding episodes.
- Danazol (Danocrine) and gestrinone are a suppressive steroids with some androgenic activity. Both agents inhibits the growth of endometriosis but their use remains limited as they may cause hirsutism. There has been some research done at Case Western Reserve University on a topical Danocrine, applied locally, which has not produced the hirsutism characteristics. The study has not yet been published in a medical journal.
- Gonadotropin releasing hormone agonists (GnRH agonists) induce a profound hypoestrogenism by decreasing FSH and LH levels. While quite effective, they induce menopausal symptoms, and over time may lead to osteoporosis. To counteract such side effects some estrogen may have to be given back (add-back therapy).
- Aromatase inhibitors are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis.
Surgical treatment is usually a good choice if endometriosis is extensive, or very painful. Surgical treatments range from minor to major surgical procedures.
- Laparoscopy is very useful not only to diagnose endometriosis, but to treat it. With the use of scissors, cautery, lasers, hydrodissection, or a sonic scalpel, endometriotic tissue can be ablated or removed in an attempt to restore normal anatomy.
- Laparotomy can be used for more extensive surgery either in attempt to restore normal anatomy, or at least preserve reproductive potential.
- Hysterectomy (removal of the uterus and surrounding tissue) and bilateral salpingoophorectomy (removal of the uterine tubes and ovaries).
- For patients with extreme pain, a presacral neurectomy may be indicated where the nerves to the uterus are cut.
Raising your serotonin level: low serotonin levels reduce the pain threshold, and make people more vulnerable to every pain. Women particularly need adequate amounts of light during the second half of their menstrual cycles, when their serotonin levels may already be low.
- Many women like to eat sweets: eating sugar or chocolate temporarily increases serotonin levels, but creates a rebound effect, characterized by heightened PMS symptoms.
- Avoid coffee and alcohol.
- Melatonin and serotonin are increased by meditation, and the stress hormone cortisol is decreased. Melatonin causes you to go into delta-sleep, during which period Human Growth Hormone is released. As melatonin levels drop from childhood (100%) to age 20 (30%) and age 30 (20%), recovering takes more time, so good deep sleep is essential.
- Serotonin is manufactured by the body from a partial protein or amino acid called tryptophan. This amino acid is found in many foods, including soy, turkey, chicken, halibut, beans.
- Lavender, primarily in the form of oil, has been found to reduce several physiological parameters of stress by stimulating serotonin and inducing a feeling of calm and happiness.
- Light therapy increases your serotonin levels.
- In the majority of cases Marijuana (Cannabis Sativa) has proven to relax or suppress the pain and remove a proportionally large amount of stress. Although doctors consider this to be an unorthodox method given all the treatments available to this condition and the fact that it may not produce any long term effects, this may still be an effective way to combat Endometriosis. Research for this method is little to none since the drug is banned in most countries and even inside those countries that support a small legal prescribed amount, the amount does not prove sufficient to effectively deal with the disease.

Prognosis

Proper counseling of patients with endometriosis requires attention to several aspects of the disorder. Of primary importance is the initial operative staging of the disease to obtain adequate information on which to base future decisions about therapy. The patient's symptoms and desire for childbearing dictate appropriate therapy. Most patients can be told that they will be able to obtain significant relief from pelvic pain and that treatment will assist them in achieving pregnancy.

Complications

The main complication of endometriosis is impaired fertility. Approximately one-third to one-half of women who have difficulty becoming pregnant have endometriosis.

For pregnancy to occur, an egg must be released from an ovary and travel through the fallopian tube to the uterus (womb), where it can be fertilized by a male's sperm and then attach to the uterine wall to begin development. Endometriosis can produce adhesions that can trap the egg near the ovary. It may inhibit the mobility of the fallopian tube and impair its ability to pick up the egg. In most cases, however, endometriosis probably interferes with conception in more complex ways.

Internal scarring
Adhesions
Pelvic cysts
Chocolate cysts
Ruptured cyst
Infertility - occurs in about 30-40% of cases.

Complications of endometriosis consist of bowel and ureteral obstruction resulting from pelvic adhesions. Rarely, endometriosis can be extraperitoneal and is found in the lungs and CNS.

Infertility

Endometriosis is associated with a lowered fertility and is the second leading cause of infertility in females that ovulate normally (the leading cause is pelvic inflammatory disease).

Treatment of Infertility

Laparoscopy to remove or vaporize the growths in women who have mild or minimal endometriosis is effective in improving fertility. One study has shown that surgical treatment of endometriosis approximately doubles the fecundity (pregnancy rate).

In patients with small amounts of endometriosis treatment with fertility medication clomiphene may lead to success.

In-vitro fertilization (IVF) procedures are effective in improving fertility in many women with endometriosis. IVF makes it possible to combine sperm and eggs in a laboratory and then place the resulting embryos into the woman's uterus. IVF is one type of assisted reproductive technology that may be an option for women and families affected by infertility related to endometriosis.

Relation to Cancer

Endometriosis is not the same as endometrial cancer. However it is hypothesized that the excess estrogen creation and abnormal cell growth caused by endometriosis may eventually cause ovarian or other cancers over a woman's lifetime. Current research has demonstrated an association between endometriosis and certain types of cancers. Endometriosis often also coexists with leiomyoma or adenomyosis, as well as autoimmune disorders.

(adapted from Wikipedia, the free encyclopedia http://en.wikipedia.org/wiki/Endometriosis)

Findings From Current Research

Nodular Endometriosis: Dynamic MR Imaging.

Authors: Onbas O, Kantarci M, Alper F, Kumtepe Y, Durur I, Ingec M, Gursan N, Okur A.

Department of Radiology, School of Medicine, Ataturk University, Erzurum, Turkey, oonbas@hotmail.com.

PURPOSE: In this study we aimed to investigate the value of contrast enhanced dynamic MR imaging (DMI) in the diagnosis of nodular abdominal endometriosis. SUBJECTS AND METHODS: Fourteen patients with surgically and pathologically proven endometriosis were examined with DMI. The patients were 22-54 years old (mean age 30.8 years). The dynamic MR studies of these patients were retrospectively reviewed by two radiologists who were aware of the clinical data. Nodular masses showing enhancement were evaluated for size, margins, and signal intensity on T1- and T2-weighted MR sequences. The protocol was tailored to selectively determine the diagnostic utility of signal intensity time course analysis for the behavior of nodular endometriosis and endometrial tissue, in DMI. Contrast-enhanced DMI was performed and the time-intensity curves of the lesions and the uterine endometrial tissue of each patient were compared. Mean enhancement values were calculated. Each DMI was evaluated for signal intensity value. RESULTS: In 8 (57%) of 14 patients, we found endometriosis in the abdominal wall. All patients with abdominal wall endometriosis had pelvic surgical operation history. Diameter of nodular endometriosis determined in the abdominus muscle ranged between 3 and 40 mm. Of eight cases, five had only one lesion and three had multiple lesions. Remaining 6 (43%) cases had deep pelvic endometriosis located in the uterosacral ligaments (n = 3), rectosigmoid (n = 2), and rectovaginal septum (n = 1). Diameter of pelvic endometriosis ranged between 9 and 53 mm. No contrast mean signal intensity of endometriosis and endometrial tissue were 280 +/- 73 and 216 +/- 20, respectively. The mean values of both endometriosis and normal endometrial tissue were calculated for each patient examined with five-slice DMI. All of the curves showed significant correlation. The lesion showed significant enhancement in the course of time similar to the endometrial tissue in all patients. CONCLUSION: Our study was inspired from the fact that endometriosis is the ectopic endometrial tissue and we thought that endometrial tissue and endometriomas should have similar vascularity. In this way imaging with MR, getting the time-intensity curves and experiencing the correlation between the endometriosis and endometrial tissue may support the diagnosis in the cases with suspected endometriosis. This first study shows that the ectopic nodular endometriosis can easily be identified with dynamic MRI. It may be used to differentiate nodular endometriosis from the other pathologic conditions of abdominal wall and pelvis.

Journal: Abdom Imaging. 2007 Apr 10;
Adapted from PubMed; click here to access full journal article.

Growth-Associated Protein 43-Positive Sensory Nerve Fibers Accompanied by Immature Vessels are Located in or Near Peritoneal Endometriotic Lesions.

Authors: Mechsner S, Schwarz J, Thode J, Loddenkemper C, Salomon DS, Ebert AD.

Endometriosis Research Center Berlin, Department of Gynecology.

OBJECTIVE: To investigate the topographical relationship between nerve fibers and peritoneal endometriotic lesions and to determine the origin of endometriosis-associated nerve fibers. DESIGN: Retrospective nonrandomized study. SETTING: University hospital endometriosis research center. PATIENT(S): Premenopausal women with histologically confirmed endometriosis were selected (n = 73). Peritoneal endometriotic lesions (n = 106) and unaffected peritoneal biopsies from patients without endometriosis (n = 9) were obtained. INTERVENTION(S): Immunohistochemistry was used to study the expression of neurofilament, substance P, smooth muscle actin, von Willebrand factor, growth-associated protein 43, nerve growth factor, and neutrophin-3 in peritoneal endometriotic lesion samples from women with symptomatic endometriosis and in peritoneal samples from women without endometriosis. RESULT(S): Pain-conducting substance-P-positive nerve fibers were found to be directly colocalized with human peritoneal endometriotic lesions in 74.5% of all cases. The endometriosis-associated nerve fibers are accompanied by immature blood vessels within the stroma. Nerve growth factor and neutrophin-3 are expressed by endometriotic cells. Growth-associated protein 43, a marker of neural outgrowth and regeneration, is expressed in endometriosis-associated nerve fibers but not in existing peritoneal nerves. CONCLUSION(S): The data provide the first evidence of direct contact between sensory nerve fibers and peritoneal endometriotic lesions. This implies that the fibers play an important role in the etiology of endometriosis-associated pelvic pain. Moreover, emerging evidence suggests that peritoneal endometriotic cells exhibit neurotrophic properties.

Journal: Fertil Steril. 2007 Apr 3;
Adapted from PubMed; click here to access full journal article.

Actuarial Analysis of Private Payer Administrative Claims Data for Women With Endometriosis.

Authors: Mirkin D, Murphy-Barron C, Iwasaki K.

BACKGROUND: Endometriosis is a painful, chronic disease affecting 5.5 million women and girls in the United States and Canada and millions more worldwide. The usual age range of women diagnosed with endometriosis is 20 to 45 years. Endometriosis has an estimated prevalence of 10% among women of reproductive age, although estimates of prevalence vary greatly. Endometriosis is the most common gynecological cause of chronic pelvic pain, but published information on its associated medical care costs is scarce. OBJECTIVE: The aim of this study was to determine (1) the prevalence of endometriosis in the United States, (2) the amount of health care services used by women coded with endometriosis in a commercial medical claims database during 1999 to 2003, and (3) the endometriosis-related costs for 2003, the most recent data available at the time the study was performed. METHODS: This study was a retrospective review of administrative data for commercial payers, which included enrollment, eligibility, and claims payment data contained in the Medstat Marketscan database for approximately 4 million commercial insurance members. All claims and membership data were extracted for each woman aged 18 to 55 years who had at least 1 medical or hospital claim with a diagnosis code for endometriosis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 617.00-617.99) for 1999 through 2003. Claims data from 1999 through 2003 were used to determine prevalence and health care resource utilization (i.e., annual admission rate, annual surgical rate, distribution of endometriosis-related surgeries, and prevalence of comorbid conditions). The cost analysis was based on claims from 2003 only. Cost was defined as the payer-allowed charge, which equals the net payer cost plus member cost share. RESULTS: The prevalence of women with medical claims (inpatient and/or outpatient) containing ICD-9-CM codes for endometriosis was 1.1% for the age band of 30 to 39 years and 0.7% over the entire age span of 18 to 55 years. The medical costs per patient per month (PPPM) for women with endometriosis were 63% greater ($706 PPPM) than those of the average woman per member per month ($433) in 2003; inpatient hospital costs accounted for 32% of total direct medical costs. Between 1999 and 2003, these women with endometriosis who were identified by either inpatient and/or outpatient claims had high rates of hospital admission (53% for any reason; 38% for an endometriosis-related reason) and a high annual surgical procedure rate (64%). Additionally, women with endometriosis frequently suffered from comorbid conditions, and these conditions were associated with greater PPPM costs of 15% to 50% for women with an endometriosis diagnosis code, depending on the condition. Interstitial cystitis was associated with 50% greater cost ($1,061 PPPM); depression, 41% ($997 PPPM); migraine, 40% ($988 PPPM); irritable bowel syndrome, 34% ($943 PPPM); chronic fatigue syndrome, 29% ($913 PPPM); abdominal pain, 20% ($846 PPPM); and infertility, 15% ($813 PPPM). CONCLUSIONS: Women with endometriosis have a high hospital admission rate and surgical procedure rate and a high incidence of comorbid conditions. Consequently, these women incur total medical costs that are, on average, 63% higher than medical costs for the average woman in a commercially insured group.

Journal: J Manag Care Pharm. 2007 Apr;13(3):262-72.
Adapted from PubMed; click here to access full journal article.

Intestinal Endometriosis. Current Status.

Authors: Bianchi A, Pulido L, Espin F, Hidalgo LA, Heredia A, Fantova MJ, Muns R, Sunol J.

Servicio de Cirugia General. Hospital de Mataro. Consorci Sanitari del Maresme. Mataro. Barcelona. Espana. abianchi@csdm.es.

Endometriosis affects a wide spectrum of premenopausal women. Intestinal involvement, affecting mainly the large bowel and sometimes the small bowel, is much less frequent. Diagnosis is relatively straightforward in women with long standing pelvic endometriosis but is difficult in acute intestinal obstruction, since a diagnosis of endometriosis is not often considered in this entity. We performed an exhaustive review of the medical literature, including the option of medical treatment, which is rarely effective in intestinal endometriosis. In most patients with intestinal symptoms, the disease is so severe that surgical treatment is required. Recent studies indicate that the most effective approach is laparoscopic. We analyze the most important classical and recent series of patients and discuss treatment results.

Journal: Cir Esp. 2007 Apr;81(4):170-6.
Adapted from PubMed; click here to access full journal article.

Infertility.

Authors: Jose-Miller AB, Boyden JW, Frey KA.

Department of Family and Community Medicine, University of Arizona, Tucson 85711, USA.

Infertility is defined as failure to achieve pregnancy during one year of frequent, unprotected intercourse. Evaluation generally begins after 12 months, but it can be initiated earlier if infertility is suspected based on history or if the female partner is older than 35 years. Major causes of infertility include male factors, ovarian dysfunction, tubal disease, endometriosis, and uterine or cervical factors. A careful history and physical examination of each partner can suggest a single or multifactorial etiology and can direct further investigation. Ovulation can be documented with a home urinary luteinizing hormone kit. Hysterosalpingography and pelvic ultrasonography can be used to screen for uterine and fallopian tube disease. Hysteroscopy and/or laparoscopy can be used if no abnormalities are found on initial screening. Women older than 35 years also may benefit from ovarian reserve testing of follicle-stimulating hormone and estradiol levels on day 3 of the menstrual cycle, the clomiphene citrate challenge test, or pelvic ultrasonography for antral follicle count to determine treatment options and the likelihood of success. Options for the treatment of male factor infertility include gonadotropin therapy, intrauterine insemination, or in vitro fertilization. Infertility attributed to ovulatory dysfunction often can be treated with oral ovulation-inducing agents in a primary care setting. Women with poor ovarian reserve have more success with oocyte donation. In certain cases, tubal disease may be treatable by surgical repair or by in vitro fertilization. Infertility attributed to endometriosis may be amenable to surgery, induction of ovulation with intrauterine insemination, or in vitro fertilization. Unexplained infertility may be managed with ovulation induction, intrauterine insemination, or both. The overall likelihood of successful pregnancy with treatment is nearly 50 percent.

Journal: Am Fam Physician. 2007 Mar 15;75(6):849-56.
Adapted from PubMed; click here to access full journal article.

Why Do They Do It? A Pilot Study Towards Understanding Participant Motivation and Experience in a Large Genetic Epidemiological Study of Endometriosis.

Authors: Treloar SA, Morley KI, Taylor SD, Hall WD.

Genetic Epidemiology Laboratory, Queensland Institute of Medical Research, Brisbane, Australia. Susan.Treloar@qimr.edu.au

OBJECTIVE: This exploratory, pilot study aimed to investigate motivations and reflections of participants who had provided epidemiological information, blood samples and access to clinical records and data in a large genetic epidemiological study of endometriosis, a common multifactorial disorder affecting women. We also aimed to explore understanding of complex genetic or multifactorial conditions in general. METHODS: In-depth interviews were conducted with 16 endometriosis study participants with diverse characteristics. RESULTS: Interviewees generally described their participation in the genetic study using altruistic frameworks of reference. Themes that emerged included unquestioning willingness and consent to participate, little concern about privacy issues, desire for more information from the researchers about the condition rather than scientific progress, the benefits of research participation to family communication, and differing ideas about genetic influences on endometriosis. Specific features of endometriosis also influenced reflections on research participation experience. CONCLUSIONS: As increasing numbers of individuals and families in the community become involved in genetic epidemiological studies of common diseases, more extensive research will be needed to better understand their expectations with a view to improving researchers' communications with study participants. Copyright 2007 S. Karger AG, Basel.

Journal: Community Genet. 2007;10(2):61-71.
Adapted from PubMed; click here to access full journal article.

Laparoscopic Management of Ureteral Endometriosis: Our Experience.

Authors: Frenna V, Santos L, Ohana E, Bailey C, Wattiez A.

Department of Obstetrics and Gynecology, Centre Medico-Chirurgical et Obstetrical-Les Syndicat inter-Hospitalier de la Communaute Urbaine de Strasbourg, Hautepierre Hospital, Strasbourg, France. virginifrenna@libero.com

STUDY OBJECTIVE: Ureteral endometriosis is rare, accounting for less than 0.3% of all endometriotic lesions. The aim of our study is to evaluate the prevalence of extrinsic ureteral endometriosis in women undergoing laparoscopic surgery for severe endometriosis and to suggest that laparoscopic ureterolysis represents a mandatory measure in all cases to avoid ureteral injury. METHODS: A retrospective analysis was performed of all cases of patients who underwent laparoscopic surgery for severe endometriosis at the departments of obstetrics and gynecology at CMCO-SIHCUS and Hautepierre Hospital, Strasbourg, from November 2004 through January 2006. MEASUREMENTS AND MAIN RESULTS: We recorded 54 patients with a mean age of 31 years and a mean body mass index of 21.9. Reported symptoms were dysmenorrhea (88%), severe dyspareunia (88%), severe pelvic pain (38.8%), and infertility (74%). Five women presented with dysuria, frequency, recurrent urinary tract infections, and pain in the renal angle, and 2 patients had hydronephrosis. We observed 3 patients (5.6%) with ureteral stenosis, 35 (64.8%) with adenomyotic tissue surrounding the ureter without stenosis, and 16 (29.6%) with adenomyotic tissue adjacent to the ureter. It was on the left side in 47.4% of cases, on the right side in 31.6% cases, and bilaterally in 21% of cases. In 9 patients, ureteral involvement was associated with bladder endometriosis (16.7%). In all patients, ureterolysis was performed. There was 1 case of ureteral injury during the procedure, 2 of transitory urinary retention, and 1 of uretero-vaginal fistula after surgery. During the first year of follow-up, the disease recurred in 4 patients, with no evidence of the disease in the urinary tract. CONCLUSION: Conservative laparoscopic surgery to relieve ureteral obstruction and remove pathologic tissue is the management of choice. Resection of part of the ureter should be performed only in exceptional cases. Ureterolysis should be performed in all patients before endometriotic nodule resection to recognize and prevent any ureteral damage.

Journal: J Minim Invasive Gynecol. 2007 Mar-Apr;14(2):169-71.
Adapted from PubMed; click here to access full journal article.

Fertility After Surgery for rAFS Stage III and IV Endometriosis.

Authors: Monti B, Varisco E, Cortese M, Calienno C, Ieda N.

Clinica Ostetrica e Ginecologica, Istituto di Scienze Biomediche San Gerardo, Monza, Milano, Italy.

AIM: The aim of this paper was to assess the impact on fertility of surgery to eradicate endometriosis. METHODS: One-hundred and twenty-six patients aged between 20 and 40 were observed. All wished to have offspring after the operation and were subjected to conservative surgery for stage III and IV endometriosis (rAFS score > 16) in the period 1992-2002. The type of surgical approach was chosen in consideration of the patient's clinical condition and on the basis of the experience of the surgeon, with the aim of radically removing the disease and, where necessary, restoring fertility. RESULTS: Fifty-six of 126 patients (44.4%) conceived after the operation; 55 spontaneously and 1 with assisted fecundation. Of the patients observed who became pregnant, about 1/3 (32%) conceived within 6 months of the operation and 1/3 (31%) after 12 months. Forty-four (78.5%) pregnancies reached term with a positive outcome, 7 (12.5%) were in progress at the moment of follow-up, 4 (7.1%) suffered a miscarriage and 1 (1.7%) was extrauterine; 48.2% (27/56 patients) of the pregnancies were stage III, 40% (28/70 patients) were stage IV. CONCLUSIONS: It emerges clearly from the data extrapolated from our series that surgery to eradicate endometriosis increases the fertility of the patients affected, without being resolutive: more than half the patients in fact remained sterile in spite of the operation.

Journal: Minerva Ginecol. 2007 Feb;59(1):27-34.
Adapted from PubMed; click here to access full journal article.

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