Electromyographic characterisation of abdominal wall trigger points developed after caesarean section and response to local anaesthesia: an observational study.

OBJECTIVE: This study examines the electromyography pattern of abdominal trigger points developed after a caesarean section, and the association between clinical response and local anaesthetic injection. DESIGN: Prospective cohort study. SETTING: A tertiary university hospital. POPULATION: Twenty-nine women with chronic pelvic pain associated with trigger points after a caesarean section were included in the study. METHODS: Participants received needle electromyography before treatment, then underwent a treatment protocol consisting of trigger-point injection of 2 ml of 1% lidocaine. The protocol was repeated once a week for 4 weeks. The clinical responses of the patients were compared 1 week after and 3 months after treatment. The clinical trial is registered with the Brazilian Clinical Trials Registry (REBEC) under RBR-42c6gz (www.ensaiosclinicos.gov.br/rg/RBR-42c6gz/). MAIN OUTCOME MEASURES: Needle electromyography and algometry results and pain reduction. RESULTS: Fifteen patients had abnormal electromyography findings; 14 had normal findings. The rates of response 1 week and 3 months after treatment within the abnormal electromyography group were 95 and 87%, respectively. In the normal group, the rate was 38% both 1 week after and 3 months after treatment. CONCLUSIONS: Trigger points developed after caesarean section, even without clinical symptoms or signs of neuralgia, may originate from neuropathies. Electromyographic abnormalities were associated with pain remission after anaesthesia injection; normal electromyography findings were associated with undiagnosed causes of pain, such as adhesions. TWEETABLE ABSTRACT: Trigger points developed after caesarean section are neuropathies, even in the absence of classical neuralgia.

Analysis of differential genetic expression in endometrial polyps of postmenopausal women.

OBJECTIVES: To evaluate the expression of four genetic markers (PTEN, BCL2, MLH1, and CTNNB1), linked to endometrial carcinogenesis, in endometrial polyps of patients with and without postmenopausal bleeding in order to determine whether symptomatic endometrial polyps have a genetic phenotype similar to that of endometrial cancer. METHODS: Samples were obtained hysteroscopically from endometrial polyps of postmenopausal patients, and the expression of genetic markers involved in the pathogenesis of endometrial cancer (PTEN, BCL2, MLH1, and CTNNB1) was analyzed. The expression of these markers was then compared between patients with and without symptoms, which was characterized as postmenopausal bleeding. Other clinical characteristics of the patients, such as duration of menopause, polyp size, presence of systemic hypertension, diabetes mellitus, and smoking habits were also analyzed. RESULTS: Samples from a total of 60 patients were obtained, as calculated for a test power of 0.80. No statistical differences (p > 0.05) were observed between the two groups concerning the expression of the studied endometrial cancer risk factor genes, or with regard to the clinical aspects evaluated. CONCLUSION: The study found no evidence that symptomatic endometrial polyps have a similar phenotype to type 1 endometrial cancer; further studies are needed in order to establish whether endometrial polyps are in fact true cancer precursors, or simply raise cancer incidence due to a detection bias.

Diagnosis of endometriosis in women with chronic pelvic pain.

PURPOSE OF INVESTIGATION: To assess the accuracy of CA-125 determination associated with clinical history and of the neutrophil/lymphocyte (N/L) ratio for a presumptive diagnosis of endometriosis in women with chronic pelvic pain (CPP). MATERIALS AND METHODS: This was a cross-sectional study of data from the medical records of women with CPP submitted to laparoscopy from August 1999 to January 2009 at the University Hospital. The performance of the evaluation of CA-125 and of the N/L ratio for the prediction of endometriosis was compared based on the corresponding ROC curves and their 95% confidence intervals. RESULTS: CA-125 levels were significantly higher in women with CPP and endometriosis and their association with a complaint of dysmenorrhea improved their sensitivity. For a cut-off of 20 IU/ml, the predictive value for a diagnosis of endometriosis in women with CPP was 97.6%. Dyspareunia, subfertility, and N/L ratio were not useful for a diagnosis of endometriosis in women with CPP. CONCLUSION: The association of elevated CA-125 levels with a complaint of dysmenorrhea is adequate in a presumptive and accurate diagnosis of endometriosis in this specific group of women with CPP, permitting an early institution of clinical treatment without the need of previous laparoscopic confirmation.

Serum markers of oxidative stress and endometriosis.

PURPOSE OF INVESTIGATION: To assess the changes secondary to chronic inflammation in women with and without pelvic endometriosis by the determination of serum thiols and carbonyls. MATERIALS AND METHODS: Sixty-seven women with endometriosis consecutively submitted to laparoscopy and 41 women without endometriosis consecutively submitted to tubal ligation (control group) were selected. Serum levels of total thiols and carbonyls were determined in both groups. RESULTS: Patients with endometriosis had significantly lower thiol levels than controls (342.37 +/- 142.09 microM vs 559.60 +/- 294.05 microM) (p < 0.001), as well as significantly lower carbonyl levels (8.97 +/- 3.76 microM vs 16.40 +/- 9.26 microM) (p < 0.001). Other clinical characteristics were not associated with changes in marker levels. The cutoff point established by the ROC curve was 396.44 microM for the thiols, with 73.1% sensitivity and 80.5% specificity, and 14.9 microM for the carbonyls, with 94% sensitivity and 51.2% specificity. CONCLUSIONS: The serum thiol levels revealed an increase in oxidative stress related to the development of pelvic endometriosis.

Immunohistochemical expression of Drosha is reduced in eutopic and ectopic endometrium of women with adenomyosis.

The objective of this study was to evaluate the immunohistochemical expression of Dicer, Drosha, and Exportin-5 in the eutopic and ectopic endometrium of women with adenomyosis. Twenty-two paired ectopic and eutopic endometrium from women with adenomyosis and 10 eutopic endometrium samples from control women undergoing hysterectomy were included in the study. Paraffin-embedded tissue blocks were cut and stained for immunohistochemistry. The percentage of epithelial cells positively marked was identified digitally after an automated slide scanning process. Mann-Whitney test or Wilcoxon signed-rank test was performed for independent and paired groups, respectively. A lower expression of Drosha was observed in the eutopic endometrium of women with adenomyosis than in the eutopic endometrium of women without the disease (69.9±3.4% vs 85.2±2.9%, respectively) (P=0.016; 95%CI: 3.4 to 27.4%). We also detected lower Drosha expression in the ectopic endometrium of women with adenomyosis than in the eutopic endometrium of the same women (59.6±3.2% vs 69.9±3.4%, respectively) (P=0.004; 95%CI: 2.3 to 16.7%). Additionally, we observed a correlation between Drosha expression in the ectopic and paired eutopic endometrium (P=0.034, rho=0.454). No significant difference in Dicer or Exportin expression was observed. Predominant pattern of cytoplasmic staining for the anti-Drosha antibody and both a nuclear and cytoplasmic pattern for the anti-Exportin antibody were observed. Drosha expression was significantly lower in the endometrium of women with adenomyosis compared to the eutopic endometrium of asymptomatic women without the disease. Furthermore, its expression was lower in the ectopic endometrium but correlated to the paired eutopic endometrium.

High levels of anxiety and depression have a negative effect on quality of life of women with chronic pelvic pain.

BACKGROUND: Chronic pelvic pain (CPP) is a common and complex disease whose cause is often clinically inexplicable, with consequent difficulty in diagnosis and treatment. Patients with CPP have high levels of anxiety and depression, with a consequent impairment of their quality of life. AIMS: The objective of this study was to determine the prevalence of anxiety and depression and their impact on the quality of life of women with CPP. MATERIALS AND METHODS: A cross-sectional controlled study was conducted on 52 patients with CPP and 54 women without pain. Depression and anxiety were evaluated by the Hospital Anxiety and Depression Scale, and quality of life was evaluated by the World Health Organization Quality of life Whoqol-bref questionnaire. Data were analysed statistically by the Mann-Whitney U-test, the Fisher exact test, chi-square test and Spearman correlation test. RESULTS: The prevalence of anxiety was 73% and 37% in the CPP and control groups, respectively, and the prevalence of depression was 40% and 30% respectively. Significant differences between groups were observed in the physical, psychological and social domains. Patients with higher anxiety and depression scores present lower quality of life scores. DISCUSSION: The fact that DPC is a syndromic complex, many patients enter a chronic cycle of search for improvement of medical symptoms. The constant presence of pain may be responsible for affective changes in dynamics, family, social and sexual. Initially the person is facing the loss of a healthy body and active, to a state of dependence and limitations. In this study, patients with higher scores of anxiety and depression scores had lower quality of life and patients with lower scores of anxiety and depression had scores of quality of life. These results show that perhaps the depression and anxiety may be related to the negative impact on quality of life of these patients. CONCLUSION: In view of this association, we emphasise the importance of a specific approach to the treatment of anxiety and depression together with clinical treatment to improve the quality of life of these patients.

Endometriosis in postmenopausal women without previous hormonal therapy: report of three cases.

INTRODUCTION: Endometriosis is a benign, estrogen-dependent, chronic gynecological disorder associated with pelvic pain and infertility. The disease most commonly affects women during the reproductive age, although postmenopausal patients do rarely present it. These rare occurrences are generally associated with hormonal use. MATERIAL AND METHODS: We present three cases of endometriosis in postmenopausal patients who have no history of hormone therapy and no previous history of endometriosis or infertility. CASE REPORTS: In case 1, a 62-year-old woman presented with acyclic pelvic pain and a left ovarian homogeneous cystic mass. After laparoscopic salpingoophorectomy and histological analysis, an ovarian endometriotic cyst was confirmed. In case 2, a 78-year-old woman presented with a painful abdominal wall mass that was confirmed by ultrasound and tomography. Her past medical history included an abdominal hysterectomy 20 years prior to the discovery of this mass. The lesion was surgically excised and histological analysis showed areas of endometrial stroma and glands surrounded by fibrosis, compatible with endometriosis. In case 3, a 54-year-old woman presented with chronic pelvic pain and a nodule in the rectovaginal septum was noted during gynecological examination. Menopause occurred at 48 years of age. She had no previous dysmenorrhea. Ultrasound confirmed the nodule in the rectovaginal septum. The patient was submitted to a diagnostic colonoscopy that revealed a friable lesion, which was subsequently biopsied. The histological diagnosis was endometriosis. CONCLUSIONS: These three cases of postmenopausal endometriosis support the celomic metaplasia theory for the genesis of this disease.

Immunohistochemical expression of Drosha is reduced in eutopic and ectopic endometrium of women with adenomyosis

The objective of this study was to evaluate the immunohistochemical expression of Dicer, Drosha, and Exportin-5 in the eutopic and ectopic endometrium of women with adenomyosis. Twenty-two paired ectopic and eutopic endometrium from women with adenomyosis and 10 eutopic endometrium samples from control women undergoing hysterectomy were included in the study. Paraffin-embedded tissue blocks were cut and stained for immunohistochemistry. The percentage of epithelial cells positively marked was identified digitally after an automated slide scanning process. Mann-Whitney test or Wilcoxon signed-rank test was performed for independent and paired groups, respectively. A lower expression of Drosha was observed in the eutopic endometrium of women with adenomyosis than in the eutopic endometrium of women without the disease (69.9±3.4% vs 85.2±2.9%, respectively) (P=0.016; 95%CI: 3.4 to 27.4%). We also detected lower Drosha expression in the ectopic endometrium of women with adenomyosis than in the eutopic endometrium of the same women (59.6±3.2% vs 69.9±3.4%, respectively) (P=0.004; 95%CI: 2.3 to 16.7%). Additionally, we observed a correlation between Drosha expression in the ectopic and paired eutopic endometrium (P=0.034, rho=0.454). No significant difference in Dicer or Exportin expression was observed. Predominant pattern of cytoplasmic staining for the anti-Drosha antibody and both a nuclear and cytoplasmic pattern for the anti-Exportin antibody were observed. Drosha expression was significantly lower in the endometrium of women with adenomyosis compared to the eutopic endometrium of asymptomatic women without the disease. Furthermore, its expression was lower in the ectopic endometrium but correlated to the paired eutopic endometrium.

Reduction of blood nitric oxide levels is associated with clinical improvement of the chronic pelvic pain related to endometriosis.

The objective of this prospective study was to determine the plasma levels of nitric oxide (NO) in women with chronic pelvic pain secondary to endometriosis (n=24) and abdominal myofascial pain syndrome (n=16). NO levels were measured in plasma collected before and 1 month after treatment. Pretreatment NO levels (µM) were lower in healthy volunteers (47.0±12.7) than in women with myofascial pain (64.2±5.0, P=0.01) or endometriosis (99.5±12.9, P<0.0001). After treatment, plasma NO levels were reduced only in the endometriosis group (99.5±12.9 vs 61.6±5.9, P=0.002). A correlation between reduction of pain intensity and reduction of NO level was observed in the endometriosis group [correlation = 0.67 (95%CI = 0.35 to 0.85), P<0.0001]. Reduction of NO levels was associated with an increase of pain threshold in this group [correlation = -0.53 (-0.78 to -0.14), P<0.0001]. NO levels appeared elevated in women with chronic pelvic pain diagnosed as secondary to endometriosis, and were directly associated with reduction in pain intensity and increase in pain threshold after treatment. Further studies are needed to investigate the role of NO in the pathophysiology of pain in women with endometriosis and its eventual association with central sensitization.

Prevalence and conditions associated with chronic pelvic pain in women from São Luís, Brazil.

The objective of the present study was to estimate the prevalence of chronic pelvic pain in the community of São Luís, capital of the State of Maranhão, Northeastern Brazil, and to identify independent conditions associated with it. A cross-sectional study was conducted, including a sample of 1470 women older than 14 years predominantly served by the public health system. The interviews were held in the subject's home by trained interviewers not affiliated with the public health services of the municipality. The homes were visited at random according to the city map and the prevalence of the condition was estimated. To identify the associated conditions, the significant variables (P=0.10) were selected and entered in a multivariate analysis model. Data are reported as odds ratio and 95% confidence interval, with the level of significance set at 0.05. The prevalence of chronic pelvic pain was 19.0%. The independent conditions associated with this diagnosis were: dyspareunia (OR=3.94), premenopausal status (OR=2.95), depressive symptoms (OR=2.33), dysmenorrhea (OR=1.77), smoking (OR=1.72), irregular menstrual flow (OR=1.62), and irritative bladder symptoms (OR=1.90). The prevalence of chronic pelvic pain in Sao Luís is high and is associated with the conditions cited above. Guidelines based on prevention and/or early identification of risk factors may reduce the prevalence of chronic pelvic pain in São Luís, Brazil.

Pain pressure threshold algometry of the abdominal wall in healthy women.

The objective of this study was to determine the inter- and intra-examiner reliability of pain pressure threshold algometry at various points of the abdominal wall of healthy women. Twenty-one healthy women in menacme with a mean age of 28 ± 5.4 years (range: 19-39 years) were included. All volunteers had regular menstrual cycles (27-33 days) and were right-handed and, to the best of our knowledge, none were taking medications at the time of testing. Women with a diagnosis of depression, anxiety or other mood disturbances were excluded. Women with previous abdominal surgery, any pain condition or any evidence of inflammation, hypertension, smoking, alcoholism, or inflammatory disease were also excluded. Pain perception thresholds were assessed with a pressure algometer with digital traction and compression and a measuring capacity for 5 kg. All points were localized by palpation and marked with a felt-tipped pen and each individual was evaluated over a period of 2 days in two consecutive sessions, each session consisting of a set of 14 point measurements repeated twice by two examiners in random sequence. There was no statistically significant difference in the mean pain threshold obtained by the two examiners on 2 different days (examiner A: P = 1.00; examiner B: P = 0.75; Wilcoxon matched pairs test). There was excellent/good agreement between examiners for all days and all points. Our results have established baseline values to which future researchers will be able to refer. They show that pressure algometry is a reliable measure for pain perception in the abdominal wall of healthy women.

Reduction of blood nitric oxide levels is associated with clinical improvement of the chronic pelvic pain related to endometriosis

The objective of this prospective study was to determine the plasma levels of nitric oxide (NO) in women with chronic pelvic pain secondary to endometriosis (n=24) and abdominal myofascial pain syndrome (n=16). NO levels were measured in plasma collected before and 1 month after treatment. Pretreatment NO levels (μM) were lower in healthy volunteers (47.0±12.7) than in women with myofascial pain (64.2±5.0, P=0.01) or endometriosis (99.5±12.9, P<0.0001). After treatment, plasma NO levels were reduced only in the endometriosis group (99.5±12.9 vs 61.6±5.9, P=0.002). A correlation between reduction of pain intensity and reduction of NO level was observed in the endometriosis group [correlation = 0.67 (95%CI = 0.35 to 0.85), P<0.0001]. Reduction of NO levels was associated with an increase of pain threshold in this group [correlation = -0.53 (-0.78 to -0.14), P<0.0001]. NO levels appeared elevated in women with chronic pelvic pain diagnosed as secondary to endometriosis, and were directly associated with reduction in pain intensity and increase in pain threshold after treatment. Further studies are needed to investigate the role of NO in the pathophysiology of pain in women with endometriosis and its eventual association with central sensitization.

Prevalence and conditions associated with chronic pelvic pain in women from São Luís, Brazil

The objective of the present study was to estimate the prevalence of chronic pelvic pain in the community of São Luís, capital of the State of Maranhão, Northeastern Brazil, and to identify independent conditions associated with it. A cross-sectional study was conducted, including a sample of 1470 women older than 14 years predominantly served by the public health system. The interviews were held in the subject's home by trained interviewers not affiliated with the public health services of the municipality. The homes were visited at random according to the city map and the prevalence of the condition was estimated. To identify the associated conditions, the significant variables (P=0.10) were selected and entered in a multivariate analysis model. Data are reported as odds ratio and 95% confidence interval, with the level of significance set at 0.05. The prevalence of chronic pelvic pain was 19.0%. The independent conditions associated with this diagnosis were: dyspareunia (OR=3.94), premenopausal status (OR=2.95), depressive symptoms (OR=2.33), dysmenorrhea (OR=1.77), smoking (OR=1.72), irregular menstrual flow (OR=1.62), and irritative bladder symptoms (OR=1.90). The prevalence of chronic pelvic pain in Sao Luís is high and is associated with the conditions cited above. Guidelines based on prevention and/or early identification of risk factors may reduce the prevalence of chronic pelvic pain in São Luís, Brazil.

Physical therapy in the management of women with chronic pelvic pain.

OBJECTIVES: Chronic pelvic pain (CPP) is defined as lower abdominal pain lasting for at least 6 months, which occurs continuously or intermittently and is not associated exclusively with menstruation or intercourse. CPP is a highly prevalent debilitating disease with negative impact on the quality of life and productivity of women. The dilemma regarding the management of CPP continues to frustrate the health professionals, partly because its physiopathology is poorly understood. Consequently, the treatment of this condition is often unsatisfactory and limited to temporary symptom relief. In the present review, we discuss characteristics of the clinical history and physical examination associated with musculoskeletal involvement in women with CPP and possible treatments, especially in the area of physiotherapy. METHODS: We evaluated data available in PubMed (1984-2006) and surveyed the reference list. Three reviewers analysed the data independently, considering a study to be of high quality if it had at least three of the following characteristics: prospective design, valid measurement instruments, and adequate sample estimate and response rate. Other studies such as retrospective investigations, reviews and expert opinions were also considered, but with decreasing emphasis. RESULTS: There are evidences of musculoskeletal system disorders in most women with CPP. These musculoskeletal disorders can be the primary cause of CPP or postural changes and pelvic muscle contractures secondary to CPP. CONCLUSIONS: Synchronised intervention by physicians and physiotherapists is becoming increasingly more necessary both in terms of a more refined diagnosis of the clinical situation and of the institution of effective and lasting treatment.

Pain pressure threshold algometry of the abdominal wall in healthy women

The objective of this study was to determine the inter- and intra-examiner reliability of pain pressure threshold algometry at various points of the abdominal wall of healthy women. Twenty-one healthy women in menacme with a mean age of 28 ± 5.4 years (range: 19-39 years) were included. All volunteers had regular menstrual cycles (27-33 days) and were right-handed and, to the best of our knowledge, none were taking medications at the time of testing. Women with a diagnosis of depression, anxiety or other mood disturbances were excluded. Women with previous abdominal surgery, any pain condition or any evidence of inflammation, hypertension, smoking, alcoholism, or inflammatory disease were also excluded. Pain perception thresholds were assessed with a pressure algometer with digital traction and compression and a measuring capacity for 5 kg. All points were localized by palpation and marked with a felt-tipped pen and each individual was evaluated over a period of 2 days in two consecutive sessions, each session consisting of a set of 14 point measurements repeated twice by two examiners in random sequence. There was no statistically significant difference in the mean pain threshold obtained by the two examiners on 2 diferent days (examiner A: P = 1.00; examiner B: P = 0.75; Wilcoxon matched pairs test). There was excellent/good agreement between examiners for all days and all points. Our results have established baseline values to which future researchers will be able to refer. They show that pressure algometry is a reliable measure for pain perception in the abdominal wall of healthy women.

p63 expression in epithelial ovarian tumors.

Ovarian cancer is a highly lethal disease and its underlying biology is poorly understood. The p63 is a homologue gene of the tumor suppressor p53. p63 appears to be important for the development and differentiation of reproductive epithelium and interacts with p53 in human tumorigenesis. This study presents the immunoexpression of the p63 in benign and malignant epithelial ovarian tumors. We evaluated the p63 immunoexpression in 91 ovarian benign cystadenomas (29 mucinous and 62 serous) and in 29 ovarian malignant tumors (3 mucinous borderline, 3 serous borderline, 17 serous carcinomas, 2 endometrioid, 2 undifferentiated, 1 mucinous, and 1 clear-cell carcinoma) using a monoclonal antibody clone 4A4 (1:200), which recognizes all p63 variants. The tumors were considered p63 positive if 5% or more cells presented nuclear immunostaining. We observed 85.7% of positivity in benign tumors, 50% in borderline tumors, and 8.7% in invasive ovarian cancer (P < .0001). The benign serous cystadenomas were positive in 91.9% of cases and benign mucinous cystadenomas in 72.4% (P= .02). These data suggests an important role of p63 in the control of ovarian epithelium behavior. The p63 may be involved in the development of benign and malignant epithelial ovarian tumors.