Endometriosis’s impact on reproductive structures and its treatment

Endometriosis is a painful, chronic disease affecting approximately 10% of all women at reproductive age, and from the most common locations where endometriosis is found: the ovary, fallopian tubes, and uterine ligaments, and, less commonly they are found in the lung, the bladder, rectum, and intestines. It is known that endometriosis, in the reproductive organs, causes pelvic pain before or during menstruation, difficulty in pregnancy or infertility, for reasons that are not entirely clear, but some theories have tried to explain this phenomenon and confirmed that it may be a result of a defect in the immune and hormonal system in addition to some factors that affect egg’s quality and the movement of the gametes and therefore reproduction function. Treatment options now focus on pain management and attempting to limit the progression of implants, using a range of hormonal medications such as anti-progesterone, progestin, oral contraceptives, and GnRH, also including surgical procedures such as endometriosis and adhesion tissue. In this review, weshed light on the damage and issues that women may face due to this disease. We discuss some alternative solutions used by specialists for patient susceptibility.

Ovarian Torsion Presentation, Treatment and Iatrogenic Surgical Management

Ovarian torsion is among the gynecological life-threatening conditions that may require urgent surgical intervention among the appearance of clinical manifestations. The most common clinical manifestations include severe abdominal pain, nausea extending to vomiting. The ovarian torsion is not limited to children only. However, it can also occur in adult females, either pregnant or non-pregnant. The etiology of the disease tends to be related to the weakness of the uterine ligaments or malpositioning of it due to known and unknown causes. Despite that, the surgical intervention is needed to release the torsion. Sometimes, it can lead to adverse events or side effects such as decreased blood flow to the surrounding structures. Which by role may lead to unpleasant complications and clinical manifestations of hemorrhage and shock. In this article, we reviewed the topic of ovarian torsion from different aspects, including the definition, causes, clinical evaluation, and clinical management and its common complications.

THE INFORMATIVE VALUE OF PELVIC ULTRASONOGRAPHY IN RECURRENT EXTERNAL GENITAL ENDOMETRIOSIS

Background. In the structure of gynecological diseases, endometriosis ranks II after inflammatory diseases of the genitals and uterine myoma. The incidence of genital endometriosis is 92–94%, with an annual incidence ranging from 0,1% to 0,3%. The disease is characterized by tumor-like type of growth, affection of adjacent organs, and severe complications that lead to disability in patients. Aim. To study the informative value of ultrasound examination of the reproductive system organs in recurrent external genital endometriosis. Material and methods. Forty-eight patients with recurrent external genital endometriosis were examined. The mean age of the patients was (34,96±1,1) years. The history of endometriosis was in the range of (10,0±1,41) years (9–11). Recurrence rate averaged (2,02±0,44) years (1–4). The duration of remission averaged (6,1±0,84) years (1–15). All the patients underwent ultrasound examination with a transvaginal transducer. The length, width, anteroposterior uterine size, M-echo, and length and width of both ovaries were determined. Echographic features of endometrioid ovarian cysts and retrocervical endometrioid infiltrate were evaluated during ultrasound examination. The findings were compared with the echographic findings in women (n=20) with no history of endometriosis (comparison group). Results and discussion. Transvaginal ultrasonography in recurrent external genital endometriosis showed a significant increase in the echographic dimensions of uterine length (54,3±0,41) mm, width (47,9±0,13) mm, anteroposterior dimension (56,1±0,18) mm, endometrial thickness (6,6±0,09) mm, and increased echographic dimensions of both ovaries (p<0,05). Transvaginal ultrasound examination is informative in the diagnosis of endometrioid ovarian cysts. In 75,6% of patients, it manifests as a fluid mass with a heterogeneous suspension. In 75% of patients, retrocervical endometrioid infiltrate manifests as a heterogeneous, hypoechogenic, painful mass located behind the uterus. Conclusion. Transvaginal ultrasound is informative in the diagnosis of endometrioid ovarian cysts. Echographic diagnosis of endometrioid infiltrates of the vesicoureteral peritoneal fold, sacroiliac, broad uterine ligaments, and pelvic peritoneum presents difficulties, which justifies the necessity of laparoscopic diagnosis.

CLINICAL CHARACTERISTICS OF PATIENTS WITH EXTERNAL GENITAL ENDOMETRIOSIS

A pairwise comparison of the clinical characteristics of patients with external genital endometriosis (EGE) stages I–III was carried out using Fisher's exact test. Patients with the most common (and newly diagnosed) stage II showed the greatest number of statistically significant correlations between clinical signs: dysmenorrheas with primary infertility (p = 0,0201), with localization of endometrioid heterotopias in the pouch of Douglas (p = 0,0214) and sacro-uterine ligaments (p = 0,0259); in addition, a relationship was found between the symptom of chronic pelvic pain and the presence of endometrioid heterotopias in the uterovesical space (p = 0,0071) and on the sacro-uterine ligaments (p = 0,0228). Along with this, they have a combination of foci of adenomyosis with multiple myoma of the uterine body was noted (p = 0,0000). In patients with stage III EGE, only one statistically significant (p = 0,0139) contingency of clinical signs was revealed — dyspareunia and heterotopias on the sacro-uterine ligaments.

DIENOGEST IN POST OPERATIVE MANAGEMENT’S OF PATIENT’S WITH ENDOMETRIOSIS

To assess the effectiveness of using dienogest in combination with postoperative interventions in patients with endometriosis. There were enrolled 102 patients with signs of external endometriosis underwent examination and surgical treatment, subdivided into 2 groups: 67 – main group (after surgical treatment, received dienogest 2 mg/day for 6 months), 35 – comparison group received no hormone therapy in the postoperative period. Surgical treatment included removal of endometrioid ovarian cysts, endometriosis foci on the pelvic peritoneum and sacral uterine ligaments. Course of the early postoperative period (up to 1 month after the intervention) as well as the long-term dynamics of the disease manifestations (3, 6, 12 and 15 months later) were assessed. Dienogest was administered after surgical treatment due to endometriosis that reduced the severity of dyspareunia and intensity of chronic pelvic pain by 3.5- and 2-fold, respectively. The probability of achieving control over uterine bleeding 6 month after the onset of treatment due to endometriosis manifested with metrorrhagia showed that combination treatment (consisting of dienogest) was 3.19-fold higher compared to surgical treatment alone (OR = 3.19; 95 % CI = 1.70–11,0; p < 0,05). Recovery of normal menstrual cycle in 63 (94.0%) women of the main group was established 1.5–2 months after completing of hormonal treatment, while in the comparison group pain and dysmenorrhea relapsed in some patients at the 6-month follow-up. Decreased libido as a side effect in patients who treated with dienogest was observed in 2 (3.0 %) women. Dienogest was highly effective in the combination treatment of patients with verified endometriosis that resulted in reduced severity of pain and metrorrhagia. The drug was featured by low level of side effects. Thus, a combination treatment of endometriosis containing dienogest at a dose of 2 mg/day applied during postoperative period allows to reduce the severity of the disease clinical manifestations and improve treatment outcome.

Prof. Paul. F. Munde. Ten Years ’experience with Alexander’s operation for schortening the round ligaments of the uterus — sixty-five cases. (American Journal of obstetrics and diseases of Women and children, 1894, August, p. 297). Ten years of experience with shortening of the round uterine ligaments (Alexander's operation), 65 cases.

Munde began to perform this operation in 1884. The results of the operation were so good that in the first year he performed it 6 times, and in 1888 he published 23 cases of it. In three of them M. did not find round ligaments, but in the remaining 20 the goal of the operation was achieved.

Mutual influence of pregnancy and childbirth on the operation of shortening the round uterine ligaments and vice versa

On the basis of theoretical considerations and conclusions from his own extensive practice, the author refutes the opinion shared by many gynecologists that the operation of shortening the round ligaments disrupts the normal course of the subsequent pregnancy, causing a miscarriage, or if pregnancy reaches the end of childbirth and in exceptional cases are again distended, and the uterus is again displaced posteriorly, as it was before the operation. According to the author, both are delusions based on theoretical considerations, and not on experience data.

Postoperative management of patients with endometriosis

Aim: to assess the effectiveness of using dienogest in combination with postoperative interventions in patients with endometriosis.Materials and methods. There were enrolled 102 patients with signs of external endometriosis underwent examination and surgical treatment, subdivided into 2 groups: 67 – main group (after surgical treatment, received dienogest 2 mg/day for 6 months), 35 – comparison group received no hormone therapy in the postoperative period. Surgical treatment included removal of endometrioid ovarian cysts, endometriosis foci on the pelvic peritoneum and sacral uterine ligaments. Course of the early postoperative period (up to 1 month after the intervention) as well as the long-term dynamics of the disease manifestations (3, 6, 12 and 15 months later) were assessed.Results. Dienogest was administered after surgical treatment due to endometriosis that reduced the severity of dyspareunia and intensity of chronic pelvic pain by 3.5- and 2-fold, respectively. The probability of achieving control over uterine bleeding 6 month after the onset of treatment due to endometriosis manifested with metrorrhagia showed that combination treatment (consisting of dienogest) was 3.19-fold higher compared to surgical treatment alone (OR = 3.19; 95 % CI = 1.70–11,0; p < 0,05). Recovery of normal menstrual cycle in 63 (94.0%) women of the main group was established 1.5–2 months after completing of hormonal treatment, while in the comparison group pain and dysmenorrhea relapsed in some patients at the 6-month follow-up. Decreased libido as a side effect in patients who treated with dienogest was observed in 2 (3.0 %) women.Conclusion. Dienogest was highly effective in the combination treatment of patients with verified endometriosis that resulted in reduced severity of pain and metrorrhagia. The drug was featured by low level of side effects. Thus, a combination treatment of endometriosis containing dienogest at a dose of 2 mg/day applied during postoperative period allows to reduce the severity of the disease clinical manifestations and improve treatment outcome.

Rare Ectopic Pregnancies – A Literature Review for the Period 2007 – 2019 on Locations Outside the Uterus and Fallopian Tubes

The majority of ectopic pregnancies (EP) are tubal pregnancies, but other implantation sites outside the uterus and tubes are also found. These rare EP locations present a particular diagnostic and therapeutic challenge. We present an overview of potential very rare locations of ectopic pregnancies, their symptoms, diagnosis and treatment, based on a systematic analysis of case reports. A literature review of the databases PubMed, Livivo and Google Scholar for the period 2007 to 2019 was carried out. A total of 113 publications were included in our review. These studies describe EP implantations in the posterior cul-de-sac, on the uterine serosa and uterine ligaments, in the vicinity of almost all intraperitoneal organs, on the abdominal wall as well as in retroperitoneal sites. The most common presenting symptom was abdominal pain occurring in different locations. The diagnostic procedures included various imaging procedures and/or explorative surgery at different advanced stages of pregnancy. The most common and preferred option was laparotomy for surgical treatment. The placenta was successfully resected in the majority of cases. A rare EP location should be considered when making a differential diagnosis in patients of child-bearing age with abdominal pain.