[Extrapelvic endometriosis is a difficult diagnosis].

Extrapelvic endometriosis is a rare type of endometriosis. The diagnosis can be challenging, especially if the patient lacks characteristic endometriosis symptoms. This case report presents a 27-year-old woman diagnosed with both primary umbilical endometriosis and infiltrating endometriosis of the diaphragm. The woman presented with a painful bluish tumour in the umbilicus and cyclic pain in her upper right abdomen, but no lower abdominal pain. Endometriosis should be one of the differential diagnoses when symptoms like pain and/or swelling is cyclic and menstrual-related.

Conservative treatment of rectosigmoid endometriosis: A prospective study.

INTRODUCTION: Deep infiltrating endometriosis is a common cause of pelvic pain. However, some patients have limited problems that may be controlled by medical treatment, so avoiding the potentially severe complications of major surgery. This approach requires detailed knowledge on quality of life and clinical symptoms over time. The aim of the study was to monitor these parameters in patients with rectosigmoid endometriosis treated with oral contraceptives, oral gestagens, and/or the levonorgestrel-releasing intrauterine device. Moreover, nodule size measurements performed with transvaginal sonography were correlated to severity of symptoms. MATERIAL AND METHODS: Conservatively treated patients on oral contraceptives, oral gestagens, or the levonorgestrel-releasing intrauterine device underwent transvaginal sonography and answered a self-administered questionnaire regarding clinical symptoms and quality of life (Short Form 36 and Endometriosis Health Profile 30) at baseline, and 6 and 12 months later. RESULTS: Eighty women completed the follow up. Scores of quality of life were comparable to normative data for Danish women of similar age and did not change with time. No association between change in size of the rectosigmoid nodule and change in symptoms was seen. CONCLUSIONS: This study supports that simple treatment with oral contraceptives, oral gestagens, or the levonorgestrel-releasing intrauterine device represents a viable therapeutic approach to rectosigmoid Deep infiltrating endometriosis, provided that proper selection of patients in need of surgery exists.

Intra- and Inter-Rater Agreement Describing Myometrial Lesions Using Morphologic Uterus Sonographic Assessment: A Pilot Study.

OBJECTIVES: To evaluate the intra- and inter-rater agreement for myometrial lesions using Morphologic Uterus Sonographic Assessment terminology. METHODS: Thirteen raters with high (n = 6) or medium experience (n = 7) assessed 30 3-dimensional ultrasound clips with (n = 20) and without (n = 10) benign myometrial lesions. Myometrial lesions were reported as poorly or well defined and then systematically evaluated for the presence of individual features. The clips were blindly assessed twice (at a 2-month interval). Intra- and inter-rater agreements were calculated with κ statistics. RESULTS: The reporting of poorly defined lesions reached moderate intra-rater agreement (κ = 0.49 [high experience] and 0.47 [medium experience]) and poor inter-rater agreement (κ = 0.39 [high experience] and 0.25 [medium experience]). The reporting of well-defined lesions reached good to very good intra-rater agreement (κ = 0.73 [high experience] and 0.82 [medium experience]) and good inter-rater agreement (κ = 0.75 [high experience] and 0.63 [medium experience]). Most individual features associated with ill-defined lesions reached moderate intra- and inter-rater agreement among highly experienced raters (κ = 0.41-0.60). The least reproducible features were myometrial cysts, hyperechoic islands, subendometrial lines and buds, and translesional flow (κ = 0.11-0.34). Most individual features associated with well-defined lesions reached moderate to good intra- and inter-rater agreement among all observers (κ = 0.41-0.80). The least reproducible features were a serosal contour, asymmetry, a hyperechoic rim, and fan-shaped shadows (κ = 0.00-0.35). CONCLUSIONS: The reporting of well-defined lesions showed excellent agreement, whereas the agreement for poorly defined lesions was low, even among highly experienced raters. The agreement on identifying individual features varied, especially for features associated with ill-defined lesions. Guidelines on minimum requirements for features associated with ill-defined lesions to be interpreted as poorly defined lesions may improve agreement.

Similar evolution of pain symptoms and quality of life in women with and without endometriosis undergoing assisted reproductive technology (ART).

INTRODUCTION: Altogether 10% of all women of fertile age suffer from endometriosis, and up to 25% of these women require assisted reproductive technology (ART) to conceive. During ART the process of controlled ovarian stimulation causes high levels of estrogen, which in theory increases the risk of the progression of symptoms related to this estrogen-dependent disorder. Because several case reports have described the worsening of endometriosis during ART we carried out this study to investigate whether controlled ovarian stimulation during ART aggravates symptoms in women with endometriosis in terms of pain and quality of life. MATERIAL AND METHODS: This prospective cohort study was based on questionnaires containing the Endometriosis Health Profile (EHP-30) and pain evaluated on the numerical rating scale (NRS). Women aged below 40 years were recruited and divided into three groups according to their endometriosis and ART status. Questionnaires were administered before and after controlled ovarian stimulation in one ART cycle. Change in EHP-30 and NRS scores from the 1st to 2nd questionnaire was analyzed. RESULTS: In total 52 women with endometriosis undergoing ART, 50 not undergoing ART, and 52 without endometriosis undergoing ART completed two questionnaires each. Both groups with endometriosis experienced a small increase in their quality of life, while women without endometriosis experienced a decrease. Pelvic pain worsened among women undergoing ART, but no greater worsening was detected among women with endometriosis compared with women without. CONCLUSIONS: This study showed no worsening in quality of life and a slight worsening in pelvic pain during ART regardless of endometriosis status.

Intra- and interobserver variability in nodule size of rectosigmoid endometriosis measured by two- and three-dimensional transvaginal sonography.

INTRODUCTION: The aim of the study was to assess the intra- and interobserver variability of two- and three-dimensional rectosigmoid nodule size measurements by transvaginal sonography in patients with rectosigmoid endometriosis. MATERIAL AND METHODS: Intra- and interobserver variability was assessed in 10 and 30 patients, respectively. Measurements in two dimensions were performed in real-time during the scan, and three-dimensional measurements of volume were done on a computer. Differences within and between observers were expressed in absolute units (mm) and percentage (%) of average nodule size. Coefficient of repeatability and Bland-Altman plots with limits of agreement were used to evaluate the intra- and interobserver variability. RESULTS: Intra- and interobserver variability in two-dimensional sonography ranged from 11 to 14 mm (46-51%) for length, 3 to 6 mm (32-57%) for depth and 5 to 9 mm (33-58%) for width of the nodule. Results of three-dimensional sonography, with assessment of nodule volume, showed intra- and interobserver variability 0.4 to 2.5 times the average nodule size. CONCLUSIONS: Measurements of rectosigmoid endometriosis nodule size with two- and three- dimensional transvaginal sonography were associated with large intra- and interobserver variability. These techniques should therefore be used with caution in clinical control and research of nodule growth.

Risk of bowel obstruction during in vitro fertilization treatment of patients with deep infiltrating endometriosis.

INTRODUCTION: Women with endometriosis often experience pain and infertility. Medical treatment interferes with the possibility of attaining pregnancy. For infertile women with endometriosis, surgery is a possible treatment, but with advanced disease there is an increased risk of serious complications. With only limited pain, women will often be referred for in vitro fertilization treatment instead. The disease is estrogen-dependent and during in vitro fertilization treatment the women could theoretically experience worsening of their symptoms. MATERIAL AND METHODS: The study is a retrospective cohort study of 76 women with bowel endometriosis who were treated conservatively and underwent in vitro fertilization treatment. RESULTS: Nine (11.8%) of the women experienced severe worsening of their bowel-related symptoms, including two patients presenting with colon ileus. One additional woman had no previous diagnosis of endometriosis before she presented with subocclusion of the bowel during in vitro fertilization. In all cases the in vitro fertilization treatment was stopped. CONCLUSIONS: Our study revealed that bowel endometriosis increases the risk of complications during in vitro fertilization treatment. This is in contrast to several publications. However, our study population is different due to the fact that none of these women had previous operations for bowel endometriosis. In all, 88% of the women completed fertility treatment without need for surgery.

Conservative approach to rectosigmoid endometriosis: a cohort study.

INTRODUCTION: The aim of the study was to assess the risk of surgery after initial conservative treatment of rectosigmoid endometriosis in relation to demographic data. MATERIAL AND METHODS: The study was conducted on the tertiary endometriosis referral unit, Aarhus University Hospital. Medical records, from patients seen from January 2009 onwards with a diagnosis of rectosigmoid endometriosis and more than 6 months' follow up were audited. Demographic data, results of magnetic resonance imaging and time to secondary surgery for rectosigmoid endometriosis were registered. RESULTS: Data on 238 patients diagnosed with rectosigmoid endometriosis were included. In all, 78 (32.8%) patients had primary surgery, 27 (11.3%) had secondary surgery and 133 (55.9%) continued conservative treatment throughout the observation period. Patients who underwent primary or secondary surgery were younger than patients continuing conservative treatment. CONCLUSIONS: In a tertiary referral center where about half of patients with rectosigmoid endometriosis were scheduled for conservative treatment, more than 80% of these avoided surgery.

[Ultrasound scan did not locate misplaced intrauterine devices].

One of the rare but serious complications of intrauterine contraception is perforation of the uterine wall at insertion. We present two cases where intrauterine devices went missing. In both cases abdominal and vaginal ultrasound scan was performed to locate the intrauterine device. They were not found and doctors concluded that the intrauterine devices were lost by expulsion. One intrauterine device came out of the rectum by itself; the other was found and removed from inside the abdomen at laparoscopy. An X-ray examination should have been done before the conclusion of expulsion.

Transvaginal ultrasonography of rectosigmoid endometriosis: interobserver variation of lesion size.

This study evaluates the interobserver variation of transvaginal ultrasonographic measurements of the size of deep infiltrating endometriosis lesions in the rectosigmoid wall performed by an experienced and a less experienced sonographer. Fifteen outpatient women were seen for a gynecologic examination and 24 women were seen with rectosigmoid endometriosis. Transvaginal ultrasonography was performed independently by two observers with a focus on the presence and size of rectosigmoid endometriosis. The senior observer had several years of experience, whereas the junior observer was a medical student with no prior experience in transvaginal ultrasonography. The findings of the two observers were identical concerning the identification of rectosigmoid endometriosis. The probability of differences in size within 30% of the mean was 0.81, 0.63 and 0.61 for length, width and depth, respectively. Our data suggest that fair skills in this technique can be acquired by inexperienced examiners within a short period of time.