Endometriosis and dysbiosis: State of art.

Endometriosis is a complex and heterogeneous disease affecting approximately 10% of reproductive age women. The hypothesis that alterations in the microbiota are involved in the pathogenesis of endometriosis has been postulated. Possible explanations for the implications of dysbiosis in endometriosis include the Bacterial Contamination hypothesis and immune activation, cytokine-impaired gut function, altered estrogen metabolism and signaling. Thus, dysbiosis, disrupt normal immune function, leading to the elevation of proinflammatory cytokines, compromised immunosurveillance and altered immune cell profiles, all of which may contribute to the pathogenesis of endometriosis. The aim of this review is to summarize the available literature data about the relationship between microbiota and endometriosis.

Ultrasound Findings of Adenomyosis in Adolescents: Type and Grade of the Disease.

STUDY OBJECTIVE: To evaluate the ultrasound features, types, and degrees of adenomyosis among adolescents and to correlate these findings with clinical symptoms DESIGN: A retrospective observational study. SETTING: Gynecological ultrasound units from January 2014 to June 2020. PATIENTS: A total of 43 adolescents (aged 12-20 years) who were diagnosed as having adenomyosis at a pelvic ultrasound examination. INTERVENTIONS: Ultrasound features and location and type of adenomyosis within the uterus were evaluated on stored 2-dimensional images and videos and 3-dimensional volumes. Adenomyosis was classified as mild, moderate, and severe according to the extension of the disease in the uterus as described in our previous published classification. MEASUREMENTS AND MAIN RESULTS: Adenomyotic features recorded among our population were myometrial hyperechoic areas, uterine wall asymmetry, intramyometrial cystic areas, and some types of junctional zone alterations. The posterior uterine wall (58%) and the outer myometrial layer (93%) were mostly affected. In 44% of adolescents (19/43) with adenomyosis, at least 1 location of pelvic endometriosis was documented. Dysmenorrhea was the most commonly reported symptoms (88%), and it was associated with adenomyosis of the outer myometrium, myometrial hyperechoic areas, uterine wall asymmetry, and intramyometrial cystic areas. Adolescents with dyspareunia showed diffuse adenomyosis (9/9 patients) including both the inner and outer myometrium (7/9 patients) and in the posterior wall (7/9 patients). Heavy menstrual bleeding was associated with diffuse adenomyosis (18/23 patients) mostly of the outer myometrium (22/23 patients). Scoring system showed predominantly mild disease and no severe adenomyosis was found. Adolescents with diffuse adenomyosis were significantly older and showed a high percentage of heavy menstrual bleeding compared with those with the focal disease of the inner myometrium. CONCLUSION: This study shows that adenomyosis is not only a pathology of adult life, but it involves young patients mostly in a mild-to-moderate form and is associated with typical painful symptoms. In adolescents, the diagnosis of adenomyosis is feasible through a noninvasive way with ultrasound and a proper management can be set.

Role of medical treatment of endometriosis.

Endometriosis is a chronic benign disease that affects women of reproductive age. Medical therapy is often the first line of management for women with endometriosis in order to ameliorate symptoms or to prevent post-surgical disease recurrence. Currently, there are several medical options for the management of patients with endometriosis and long-term treatments should balance clinical efficacy (controlling pain symptoms and preventing recurrence of disease after surgery) with an acceptable safety-profile. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in the treatment of chronic inflammatory conditions, being efficacious in relieving primary dysmenorrhea. Combined oral contraceptives and progestins, available for multiple routes of administration, are commonly administered as first-line hormonal therapies. Several studies demonstrated that they succeed in improving pain symptoms in the majority of patients; moreover, they are well tolerated and not expensive. Gonadotropin-releasing hormone-agonists are prescribed when first line therapies are ineffective, not tolerated or contraindicated. Even if these drugs are efficacious in treating women not responding to COCs or progestins, they are not orally available and have a less favorable tolerability profile (needing an appropriate add-back therapy). Because few data are available on long-term efficacy and safety of aromatase inhibitors they should be reserved only for women with symptoms who are refractory to other treatments only in a research environment. Almost all of the currently available treatment options for endometriosis suppress ovarian function and are not curative. For this reason, research into new drugs is unsurprisingly demanding. Amongst the drugs currently under investigation, gonadotropin-releasing hormone antagonists have shown most promise, currently in late-stage clinical development. There is a number of potential future therapies currently tested only in vitro, in animal models of endometriosis or in early clinical studies with a small sample size. Further studies are necessary to conclude whether these treatments would be of value for the treatment of endometriosis.

Management of perimenopause disorders: hormonal treatment.

Perimenopause represents a transition period of a woman's life during which physiological, affective, psychological, and social changes mark progression from a woman's fertile life to menopause, with wide sexual hormones fluctuations until the onset of hypergonadotropic hypogonadic amenorrhea. Contraception during menopause should not only avoid unwanted pregnancies, but also improve quality of life and prevent wide range of condition affecting this population. Hormonal contraceptives confer many noncontraceptive benefits for women approaching menopause: treatment of abnormal uterine bleeding, relief from vasomotor symptoms, endometrial protection in women using estrogen therapy, musculoskeletal protection, and mood disorders protection. The main point remains selecting the most adequate contraceptive option for each woman, considering her risk factor, comorbidities, and keeping in mind the possibility of continuing contraception until reaching menopause and even further, creating a bridge between perimenopause and menopause hormonal therapy. Correct perimenopause management should rely on individualized medical therapy and multidisciplinary approach considering lifestyle and food habits as part of general good health of a woman.

Pathophysiologic mechanisms by which adenomyosis predisposes to postpartum haemorrhage and other obstetric complications.

Adenomyosis is characterized by the presence of ectopic endometrium within the myometrium. This features lead to structural changes in the surrounding myometrium and endometrium resulting also in functional changes. Alterations in the myometrium are suspected to lead to defective remodeling of spiral arteries during the early stages of decidualization resulting in altered vascular resistance and defective placentation. These alterations could play a common part in the association between adenomyosis and major obstetric complications. Latest epidemiological studies show that adenomyosis is associated with preterm birth, preeclampsia, IUGR and increased caesarean section rates, but very little is known of any underlying mechanism linking postpartum hemorrhage and adenomyosis. It is our opinion that adenomyosis may increase the risk of postpartum hemorrhage through several mechanisms that will be further clarified. Women with adenomyosis may require specific management during pregnancy and may benefit from wider understanding of the pathological mechanisms associated with this disease process.