Pelvic endometriosis

Bese T, Simsek Y, Bese N, Ilvan S, Arvas M (2003) Extensive pelvic endometriosis with malignant change in tamoxifen-treated postmenopausal women. Int J Gynecol Cancer 13 376-380... 

Epidemiological studies of the relation between oral contraceptive use and pelvic endometriosis have variously shown an increased risk, a reduced risk, and no effect (268). For example, an Italian study showed an increased risk among ever users of oral contraceptives, but this increase occurred only among former users, not current users (269). Furthermore, the authors noted that a similar pattern had been shown in several large cohort studies (OFPA, RCGP, and Walnut Creek). There was no association in the Italian study with recency, latency, or... 

Parazzini F, Ferraroni M, Bocciolone L, Tozzi L, Rubessa S, La Vecchia C. Contraceptive methods and risk of pelvic endometriosis. Contraception 1994 49(l) 47-55. 

Igarashi, M., et al. 1998. Novel vaginal danazol ring therapy for pelvic endometriosis, in particular deeply infiltrating endometriosis. Hum Reprod 13 1952. 

Igarashi, M. 1990. A new therapy for pelvic endometriosis and uterine adenomyosis Local effect of vaginal and intrauterine danazol application, Asia-Oceania. J Obstet Gynaecol 16 1. 

Rings containing danazol were designed to control and treat pelvic endometriosis. Danazol acts directly on endometriotic tissue, inhibits DNA synthesis, and induces cell apoptosis. Danazol locally administered did not show inhibition of ovulation on the contrary, oral administration produced a lack of menstrual cycle. Consequently, the main mechanism of action after local administration was reported to be the direct action on endometriotic cells. Danazol probably diffuses through vaginal mucosa and reaches the deep layers, where infiltrating endometriosis takes place. This behavior allows for the avoidance of the side effects, which characterize oral therapy [41]. 

Houston, D.E. 1984. Evidence for the risk of pelvic endometriosis by age, race and socioeconomic status. Epidemiol. Rev. 6 167-191. 

Danazol Treatment of pelvic endometriosis Ring and vaginal suppository Effective without increased serum concentrations observed during oral therapy 114... 

Stripling MC, Martin DC, Chatman DL, Zwaag RV, Poston WM (1988) Subtle appearances of pelvic endometriosis. Fertil Steril 49 427-431... 

Bazot M, Thomassin I, Hourani R, Cortez A, Darai E (2004) Diagnostic accuracy of transvaginal sonography for deep pelvic endometriosis. Ultrasound Obstet Gynecol 24 180-185... 

Bazot M, Darai E, Hourani R, Thomassin I, Cortez A, Uzan S, Buy JN (2004) Deep pelvic endometriosis MR imaging for diagnosis and prediction of extension of disease. Radiology 232 379-389... 

Magnetic resonance (MR) imaging is suitable for assessing female infertility, as infertility typically results from benign processes in women of reproductive age. The causes of female infertility include ovulatory disorders (i.e., pituitary adenoma and polycystic ovarian syndrome), disorders of the fallopian tubes (i.e., hydrosalpinx and pelvic inflammatory disease), uterine disorders (i.e.,mullerian duct anomaly, aden-omyosis, and leiomyoma), and pelvic endometriosis. 

Thus, our attention should shift from the concern of potential adverse effects to the health benefits imparted by hormonal contraceptives. The use of oral contraceptives for at least 12 months reduces the risk of developing endometrial cancer by 50%. Furthermore, the risk of epithelial ovarian cancer in users of oral contraceptives is reduced by 40% compared with that on nonusers. This kind of protection is already seen after as little as 3-6 months of use. Oral contraceptives also decrease the incidence of ovarian cysts and fibrocystic breast disease. They reduce menstrual blood loss and thus the incidence of iron-deficiency anemia. A decreased incidence of pelvic inflammatory disease and ectopic pregnancies has been reported as well as an ameliorating effect on the clinical course of endometriosis. 

Taking the contraceptive hormones provides health benefits not related to contraception, such as regulating the menstrual cycle and decreased blood loss, and incidence of iron deficiency anemia, and dysmenorrhea Health benefits related to the inhibition of ovulation include a decrease in ovarian cysts and ectopic pregnancies. hi addition, there is a decrease in fibrocyctic breast disease, acute pelvic inflammatory disease endometrial cancer, ovarian cancer, maintenance of bone density, and symptoms related to endometriosis in women taking contraceptive hormones. Newer combination contraceptives such as norgestimate and ethinyl estradiol... 

The most significant mechanism for primary dysmenorrhea is the release of prostaglandins in the menstrual fluid and possibly vasopressin-mediated vasoconstriction.5,17 Causes of secondary dysmenorrhea may include cervical stenosis, endometriosis, pelvic infections, pelvic congestion syndrome, uterine or cervical polyps, and uterine fibroids.20... 

The main manifestations and symptoms of endometriosis are infertil-ity/subfertility and pelvic pain (Missmer et al. 2003 Olive et al. 2001). Retrospective data have, in fact, shown that women with subfertility are at a high risk of having endometriosis, and prospective studies have demonstrated that endometriosis is related to a low relative risk for pregnancy (D Hooghe et al. 2003 Akande et al. 2004). 

In addition, about 15% of cases of pelvic pain are due to endometriosis, and most primary care physicians consider pelvic pain to be a common clinical problem that accounts for as much as 25% of routine gynecologic office visits (Hurd 1998). Endometriosis is frequently associated with several types of pelvic pain such as dysmenorrhea, chronic pelvic pain, deep dyspareunia, and, occasionally, painful defecation (Hurd 1998). Specifically, endometriosis was... 

The severity of pelvic pain and the incidence of infertility are not related to the localization of the lesions or to the stage of the disease (Gruppo Ital-iano per lo Studio dell Endometriosi 2001), as categorized according to the revised American Fertility Society (r-AFS) guidelines (American Fertility Society 1985). In fact, the r-AFS classification system is inadequate to express the severity of the symptomatology because it does not reflect the disease in terms of cellular mass or activity. 

When pelvic pain is the characterizing symptom of the disease, medical treatment could have a significant role. Several medical treatments have been proposed to treat secondary chronic pelvic pain due to endometriosis (Stones et al. 2004). Moreover, few data are available regarding the effectiveness of the treatments for endometriosis on the quality of life of these patients that seems to be deeply impaired (Carter 1998). 

Like the medical treatment of uterine leiomyomas, danazol, gestrinone, mifepristone, and GnRH-a, with or without add-back therapy, have been proposed for the treatment of endometriosis as well (Olive et al. 2001 Stones et al. 2004), but unlike leiomyomas, oral contraceptive pills, in cyclic or continuous administration, and medroxyprogesterone acetate also seem to be effective (Olive et al. 2001 Stones et al. 2004). A significant benefit in terms of pelvic pain relief also is obtained with the use of nonsteroidal anti-inflammatory drugs (Olive et al. 2001 Stones et al. 2004). 

Furthermore, about 20% of women with chronic pelvic pain due to endometriosis are not responsive to medical treatment, and in these cases surgery represents the final diagnostic and therapeutic option (Olive et al. 2001 Stones et al. 2004). Several procedures have been described to treat medically unbeatable pelvic pain (Carter 1998). Nonconservative procedures, such as hysterectomy (Rannestad et al. 2001 Lefebvre et al. 2002), are effective in terms of pain relief, but they can be associated to the decrease in the quality of life (MacDonald et al. 1999), and considered unacceptable to women who wish to preserve intact their reproductive apparatus. 

Hurd WW (1998) Criteria that indicate endometriosis is the cause of chronic pelvic pain. Obstet Gynecol 92 1029-1032... 

Sutton CJ, Ewen SP, Whitelaw N (1994) Prospective, randomized double-blind controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild and moderate endometriosis. Fertil Steril 62 696-700... 

Endometriosis is abnormal growth of endometrial tissue in the peritoneal cavity. Women with this disorder have dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. Danazol (Danocrine) is a 2,3-isoxazol derivative of 17a-ethynyl testosterone (ethisterone) that has weak virilizing and protein anabolic properties. It is effective in endometriosis through its negative feedback... 

Uterine leiomyomata are benign, estrogen-sensitive, fibrous growths in the uterus that can cause menorrhagia, with associated anemia and pelvic pain. Treatment for 3-6 months with a GnRH agonist reduces fibroid size and, when combined with supplemental iron, improves anemia. Leuprolide, goserelin, and nafarelin are approved for this indication. The doses and routes of administration are similar to those described for treatment of endometriosis. 

Danazol is a weak androgen and can thus exert the adverse effects of androgens, but because it inhibits LH and FSH secretion it can also elicit menopausal-like symptoms. However, from time to time it has other types of adverse effect. It has been used with some success in the management of pelvic pain associated with endometriosis (1), heavy menstrual bleeding (2), and idiopathic thrombocytopenic purpura (3). It is ineffective in unexplained subfertility (4). 

Selak V, Farquhar C, Prentice A, Singla A. Danazol for pelvic pain associated with endometriosis. Cochrane Database Syst Rev 2007 (4) CD000068. 

Very recently, clinical assessments of an IUD releasing danazol for the treatment of endometrial hyperplasia and endometriosis-related pelvic pain have been reported [86,87]. 

Corbellis, L., et al. 2004. A danazol-loaded intrauterine device decreases dysmenorrheal, pelvic pain, and dyspareunia associated with endometriosis. Fertil Steril 82 239. 

Endometriosis. Endometriosis is a condition characterized by growths of uterinelike tissue that occur at various locations within the pelvic cavity. Progesterone and estrogen-progesterone combinations help suppress bleeding from these tissues and may help shrink the size of these growths. 

The endometrium is the tissue that lines the inside of the uterus. Endometriosis is a condition where endometrial tissue is found outside the uterus. It is trapped in the pelvic area and lower abdomen. The exact cause is unknown. A reflux of menstruation occurs in many women but in endometriosis refluxed cells implant in the pelvis, bleed in response to cyclic hormone stimulation and increase in size. Patches of endometriosis can cause adhesions and form into cysts which can fill with thick fluid and are known as chocolate cysts. 

Case study level 1 - Primary dysmenorrhoea 150 Case study level 2 - Urinary tract infections in pregnancy 151 Case study level 3 - Pelvic inflammatory disease 152 Case study level Ma - Endometriosis management in secondary care 154... 

Although most treatments for endometriosis are directed at the implant themselves, the symptoms can be also treated directly. Nonsteroidal antiinflammatory drugs (NSAID) such as diclofenac, ibuprofen, mefenamic acid, are often given to relieve the pain associated with endometriosis. These drugs are frequently the first-line treatment in women with pelvic pain whose cause has not yet been proved to be endometriosis. 

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