Accuracy of ultrasound signs on two-dimensional transvaginal ultrasound in prediction of adenomyosis: prospective multicenter study.

OBJECTIVE: Two-dimensional (2D) transvaginal ultrasound (TVS) is an accessible and cost-effective diagnostic tool for the detection of adenomyosis. Different ultrasound features related to adenomyosis have been described, but the predictive value of each ultrasound sign and their combinations requires further investigation. We aimed to analyze the accuracy of 2D-TVS and describe possible combinations of ultrasound signs with a high predictive value in the diagnosis of adenomyosis. METHODS: This was a prospective multicenter study of patients scheduled for laparoscopic hysterectomy who had been examined using standardized 2D-TVS at nine expert centers specializing in the diagnosis and treatment of endometriosis. 2D-TVS examination included nine typical adenomyosis ultrasound features, comprising heterogeneous myometrium, myometrial linear striations, myometrial cysts, subendometrial microcysts, asymmetrical myometrial thickening, uterine enlargement, the 'question mark sign', thickening of the junctional zone and hyperechoic myometrial spots, in order to predict or exclude the presence of adenomyosis. Ultrasound examination results were compared with histology after hysterectomy. The diagnostic reliability of the nine ultrasound signs and their combinations, and the influence of concurrent fibroids on the accuracy of the results, were analyzed. RESULTS: A total of 202 patients were enrolled into the study. Histopathological examination revealed adenomyosis in 130 patients (64.4%). The accuracy of prediction of adenomyosis by 2D-TVS examination using all signs was 63.4% (positive predictive value, 71.5%; negative predictive value, 48.6%; sensitivity, 71.5%; specificity, 48.6%). Heterogeneous myometrium, myometrial cysts, subendometrial microcysts and hyperechoic myometrial spots showed the highest accuracy (55.7-62.1%) as individual ultrasound signs for the prediction of adenomyosis. The combination of the most accurate ultrasound signs (subendometrial microcysts, myometrial cysts and heterogeneous myometrium) improved the specificity of prediction (86.1%) when compared with that of these three single markers (35.2-81.7%). Uterine enlargement and asymmetry showed both low sensitivity (60.8% and 52.3%, respectively) and specificity (41.7% and 49.3%, respectively) as individual sonographic signs. CONCLUSIONS: Heterogeneous myometrium, myometrial cysts, subendometrial microcysts and hyperechoic myometrial spots showed the highest accuracy for the detection of adenomyosis in this study, while uterine enlargement and asymmetry led to high false-positive and false-negative results. A combination of ultrasound features including the most accurate signs increases specificity. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Implementation of certified endometriosis centers: 5-year experience in German-speaking Europe.

The idea of quality improvement in the management of endometriosis has been brought to attention throughout Europe. This - first and foremost - includes the implementation of centers specialized in treating endometriosis. This leads to qualification of both physicians and other medical staff, enforcement of research efforts, and informing the patients, the public, politicians, healthcare providers, and industry. Given limited budgets, focusing on the existing national commitment may be the first step.

The cost-effective, but forgotten, medical endometriosis therapy: a prospective, quasi-randomized study on progestin therapy.

Endometriosis represents nowadays a real burden for the patients as well as for the physicians, as it requires surgical and/or medical treatment, often long - termed and repeated. Moreover, the high costs necessary to diagnose and treat endometriosis represent a real economic burden, being comparable to other chronic diseases like diabetes or rheumatoid arthritis. Therefore, the physicians dealing with this disease should take into account not only the efficacy of the treatment, but also the economic aspects and patients compliance. The present paper analyses the efficiency of progestins (lynestrenol and medrogestone) in endometriosis as a cost - effective, but forgotten medical therapy of the disease. Our study underlines the good tolerability of progestins, as they have limited side effects, the compliance of patients being high. They are also low-cost medications, which could represent an effective alternative method in the endometriosis treatment, especially in less - developed countries that cannot afford the higher therapeutic costs.

Diagnostics and Therapy for Malignant (Degenerate) Colon Endometriosis - Three Case Reports.

Malignant degeneration of colon endometriosis is a very rare event. We report here on three cases. A 48-year-old woman with a 10-year history of endometriosis was treated for a rectal adenocarcinoma, a 61-year-old G1P1, who was operated at the age of 40 years for ovarian endometriosis and again at the age of 53 years for an endometriosis-associated endometroid ovarian carcinoma, presented for therapy for a lymph node recurrence of the ovarian cancer and, secondly, due to a malignantly degenerated rectum-sigmoid colon endometriosis; furthermore a 54-year old woman with a 21-year history of endometriosis was operated for malignant colon endometriosis. The tumour occurred during an adjuvant anti-oestrogen treatment with an aromatase inhibitor following surgical and radiotherapy for breast cancer. In all cases a radical cancer operation was followed by adjuvant chemotherapy and in one case with an additional radiotherapy. In the follow-up periods of 18 months, 2 and 5 years, respectively, all women remained free of recurrences. Although this is not a randomised controlled study due to the rare occurrence of such cases, a radical operation followed by individualised adjuvant therapy appears to be the treatment of choice.

Clinical data of granulosa cell tumors.

Clinical data from Granulosa cell tumors (GCT) of the ovary were compared with data from 528 cases of malignant ovarian tumor in regard to symptomatology, treatment and prognosis. GCT are more frequent under the age of 30 and their biology requires a clinical separation from other feminizing mesenchymal tumors. Irregularities of uterine bleeding as a result of hormonal activity were the most frequent symptoms, explaining why their diagnosis is earlier than in ovarian cancer. The 5-year survival rates were similar when tumor stages were compared. GCT is associated with a frequency of late recurrences after 5, 10 or more years but a potential risk of malignancy is not related to clinical or histological criteria. Abdominal hysterectomy with bilateral salpingoophorectomy is standard treatment, whereas radiation and chemotherapy seem to be of little value.

Primary carcinoma of the vagina. An analysis of 82 cases of squamous cell carcinoma.

Between 1949 and 1978, 82 patients with primary squamous cell carcinoma of the vagina were treated at the Universitäts-Frauenklinik Münster. The treatment consisted of a combination of intravaginal radium application and external beam radiation. The -5-year survival rate in patients with state I (FIGO) was 68.4%. None of the stage IV patients survived for more than 3 years.

Ultrastructural changes in endometriotic implants during the menstrual cycle.

This report, the first ultrastructural study of endometriotic implants, compares the ectopic endometrium in 14 patients with that found in the uterus. The ultrastructural features of most of the glands of the ectopic endometrium resemble those of the corresponding glands lining the uterus. Specific ultrastructural characteristics associated with ovulation, such as giant mitochondria and nuclear channel systems, however, could not be detected in ectopic tissue. Although no pathognomonic electron microscopic characteristics were found in the ectopic endometrium, it was generally possible to assign each sample to a particular phase of the menstrual cycle.

Goserelin (Zoladex) depot in the treatment of endometriosis. Zoladex Endometriosis Study Group.

STUDY OBJECTIVE: To evaluate the safety and efficacy of Goserelin (Zoladex depot; ICI Pharmaceuticals, Macclesfield, Cheshire, United Kingdom) in the treatment of endometriosis. DESIGN: Open study. SETTING: Eleven centers in Germany and 1 center in Austria. PATIENTS: One hundred forty-six patients with pelvic endometriosis. INTERVENTION: Goserelin (Zoladex depot) therapy, one depot (3.6 mg) subcutaneously every 4 weeks for 6 months. RESULTS: Total subjective score and total pelvic symptom score showed a reduction by 86% and 93%, respectively, at the end of the treatment and did not exceed one fifth of the pretreatment value throughout the follow-up period of 48 weeks. One hundred seven women underwent a second laparoscopy at the end of the therapy for determination of objective efficacy: 54% of the patients showed a reduction of implants and adhesions by at least 50% or more, and 31.5% had a complete resolution of visible deposits. The mean reduction of implants and adhesions was 50%, and the mean reduction of implants 72%. Twenty of 64 (31.3%) previously infertile patients successfully conceived within 12 months after discontinuation of the therapy. Goserelin led to a down regulation of the pituitary ovarian axis and as a pharmacological effect of this hypoestrogenism most patients had hot flushes and vaginal dryness. CONCLUSIONS: Zoladex depot therapy proved to be safe and effective in the medical treatment of endometriosis.

Ultrastructural changes in endometriotic tissue during danazol treatment.

Electron microscopic examinations were carried out on 29 representative endometriotic glands obtained from 16 biopsies. Patients with endometriosis diagnosed by laparoscopy and confirmed by laparoscopic biopsy prior to hormonal treatment received danazol, 800 mg daily. The tissue samples were obtained after 2, 4, and 6 months of usage of the drug to study the ultrastructural effect of this treatment. The glandular epithelium appeared to be arrested in what looked like the late proliferative stage of the normal menstrual cycle. The ciliated cells remained unchanged for the most part. The findings were correlated with possible effects of danazol on the target tissue, but caution is required in the interpretation of ultrastructural effects of steroids until detailed knowledge of the metabolic pathways is available.

Changes of prolactin secretion following long-term danazol application.

Patients (n = 10) with endometriosis or fibrocystic mammary disease were treated with an oral dose of 4 x 200 mg danazol for 6 months. Prolactin and gonadotropin secretion was evaluated before, and in some of them during 1, 3, and 6 months of therapy, as well as 4 weeks after discontinuation of the steroid. Prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol, and progesterone were measured before a bolus of 10 mg metoclopramide and 25 micrograms LH-releasing hormone (LH-RH) had been given. The serum concentrations of prolactin and LH were estimated 25 minutes and those of FSH 45 minutes thereafter. Basal and stimulated serum prolactin levels, measured during the luteal phase of the control cycle preceding danazol application, decreased continuously, reaching serum concentrations seen during the early follicular phase of the cycle. This was paralleled by a decrease of estradiol and a lack of progesterone secretion. While basal and LH-RH-stimulated LH was practically unchanged, basal and stimulated FSH showed a significant increase. Within 4 weeks of discontinuation of the drug all hormonal parameters were similar to pretreatment values. The data presented may explain the beneficial effect of the drug on fibrocystic mammary disease, i.e., by the decrease of serum and pituitary prolactin. The selective increase of FSH secretion is unclear but may reflect the lack of negative feedback mechanisms of follicular inhibin.

Recommendations for estrogen and progestin replacement in the climacteric and postmenopause. European Progestin Club.

The diversity of function that sex steroids have proven to have in the female body, gives them a position of central importance in gynaecology. Scientific research demonstrates not only the well known genital functions of sexual steroids, furthermore, various extragenital organs are influenced and modulated by ovarian hormones. Therefore, the general benefit of HRT for the female organism becomes clearer and the clinical management of menopause is developing to a broad new discipline, the gender specific medicine. In clinical practise, phytosteroids are claimed by the patient and therefore, also of high interest for the scientific research. Also, tissue specificity of the endocrine treatment and the biological relevance of different steroid receptors of HRT are discussed, leading to the development of new HrT preparations. Individualisation, the tailoring of HRT, according to the patients needs, and low dose steroids management, will also become an important aspect in the recommendations for estrogen and progestin replacement therapy.

Aspects of progestin activity on the breast. European Progestin Club.

On 9-11 May 1997, the second Meeting of the European Progestin Club was held in Turin, Italy. Aspects of progestin use on the breast were discussed, based on the currently available scientific data. The paper covers topics addressed at the meeting and summarizes the recommendations which could be agreed on by the participants.

Endocrine dependency of endometriosis: an ultrastructural study.

The comparison of the ultrastructural features of endometriotic implants in 96 patients before and after suppressive therapy by danazol showed that the glands of the ectopic endometrium had a wide range of morphologic development. In about one-third of the pretreatment biopsies significantly different ultrastructural patterns were observed in the same specimen, ranging from poorly to highly differentiated endometrial glands. Adequate morphological changes during the menstrual cycle were found in implants only in 14 patients during the proliferative phase, but adequate, homogeneously performed secretory changes were completely missing during the luteal phase. Besides incomplete or delayed secretory changes the majority was proliferative rather than secretory. After 6 months of endocrine suppression laparoscopic biopsies of endometriosis were repeated, and the ultrastructural findings lead to three conclusions. 1. Poorly differentiated endometriotic foci do not respond to danazol. 2. Endometriotic implants consisting of highly differentiated epithelium with adequate cyclic variations respond well to danazol and disappear in nearly 80% of cases. 3. In endometriosis with mixed areas consisting of various degrees of glandular differentiation the hormonal suppression can eliminate endometriotic implants or arrest them at a proliferative stage. If the morphological appearance of the ectopic implants depends not simply upon the endocrine stimulus, but primarily on the degree of differentiation and maturity of the cell, then perhaps cyclic modulation is only a secondary phenomenon, and hormones play only a secondary role in therapy. If this hypothesis is correct, only complete elimination of endocrine influence can cure endometriosis. Transient or incomplete suppression may lead only to partial regression.

[Abortion by means of suction curettage compared to the conventional metal curettage]. / Schwangerschaftsunterbrechung durch Saugkürette im Vergleich zur konventionellen Metallkürette.

PIP: 47 women in the first trimester of pregnancy underwent induced abortion, 23 by vacuum aspiration and 24 by classical dilatation and curettage. All operations were performed under nearly identical conditions. In 5 cases in each group, a hysteroscopy was performed. Both techniques evacuated the uterus sufficiently. Vacuum aspiration is quicker, simpler, and requires dilatation only to Hegar 8. Less blood is lost during vacuum aspiration, and a more thorough evacuation of the uterus with less endometrial trauma is effected. Vacuum aspiration is recommended for induced abortion in the first trimester of pregnancy.^ieng

National German Guideline (S2k): Guideline for the Diagnosis and Treatment of Endometriosis: Long Version - AWMF Registry No. 015-045.

In this guideline, recommendations and standards for optimum diagnosis and treatment of endometriosis are presented. They are based on the analysis of the available scientific evidence as published in prospective randomized and retrospective studies as well as in systematic reviews. The guideline working group consisted of experts from Austria, Germany, Switzerland, and the Czech Republic.

Surgical Therapy of Endometriosis: Challenges and Controversies.

Endometriosis is one of the most common disorders encountered in surgical gynaecology. The laparoscopic technique, the planning of the surgical intervention, the extent of information provided to patients and the interdisciplinary coordination make it a challenging intervention. Complete resection of all visible foci of disease offers the best control of symptoms. However, the possibility of achieving this goal is limited by the difficulty of detecting all foci and the risks associated with radical surgical strategies. Thus, the excision of ovarian endometrioma can result in a significant impairment of ovarian function, while damage to nerve structures during resection of the uterosacral ligaments, the parametrium, the rectovaginal septum or the vaginal cuff to treat deep infiltrating endometriosis can lead to serious functional impairments such as voiding disorders. A detailed risk-benefit analysis is therefore necessary, and patients must be treated using an individual approach.