1073
10. Brady MT, Evans J, Cuartas J. Survival and disinfection of parainfluenza viruses on environmental surfaces. Am J Infect Control 1990; 18: 18-23.
Endometriosis: time for reappraisal Endometriosis is the presence of tissue histologically similar to endometrium outside the uterine cavity and myometrium. The original of blue-black or "powder-burn" lesions, or ovarian cysts containing dark brown "chocolate" material. By causing an inflammatory reaction endometriosis precipitates pain and local damage that can ultimately lead to tubal occlusion or ovarian enclosure by fibrous tissue, and infertility. Until lately the condition was diagnosed only in those patients undergoing a laparotomy for a pelvic mass or pain. These women were a highly selected subgroup with an obvious mass or pain severe enough to warrant an invasive procedure, and the disease was perceived as uncommon. Use of laparoscopy early in the investigation of patients with infertility, pelvic or lower abdominal pain, and for sterilisation greatly enhanced our ability to inspect the pelvis and the new information generated has led to a reappraisal of
descriptions
were
endometriosis. Small lesions can be seen at laparoscopy in many women both with and without symptoms. The condition is commoner in those with infertility or the reported frequency in women being sterilised is risingi-an indication that doctors are increasingly sensitive to the diagnosis. Moreover, we now know that histological evidence of endometriosis can be found in many types of lesions other than the classic blue-black variety; for instance,endometriosis tissue has been found in over 50% of biopsy specimens from vesicular, haemorrhagic, and papular lesions, areas of fibrous scarring, and peritoneal defects.2 Histological evidence of endometriosis has even been found in up to 13% of peritoneal specimens that were apparently normal at biopsy.3 As a result of these observations some researchers have questioned whether endometriosis is a disease at all.4,5 If endometriosis is a common condition, visual diagnosis alone does not constitute a requirement to treat. The evidence that successful medical treatment of endometriosis in infertile women does not improve their fertility accords with this view.6,7 Although laparoscopic diagnosis of symptomless endometriosis is commoner in infertile women than in fertile controls, a group of European experts5 lately concluded that there can be no support for drug treatment of mild endometriosis in infertile women. Early reports of placebo-controlled trials suggested that the disease progressed in some patients and that, since progression was unpredictable, all patients should be treated.8 Subsequent studies showed that in over 50% of untreated patients the disease either improves or does not deteriorate/,1Q so there is little justification for such a therapeutic strategy. Furthermore, there is evidence that endometriosis
pain;
medical therapy is stopped-ie, the probably suppressing the disease rather than drugs it. 11 eradicating Thus, although endometriosis can unquestionably cause severe pelvic pain and destruction, lesions detected at laparoscopy may be incidental. It is therefore important to assess whether the patient’s symptoms are typical of endometriosis before attributing causality. Pain in endometriosis is usually cyclical and is precipitated by intercourse or defaecation. Physical signs such as a mass or tenderness are important confirmatory findings. In a patient with this constellation of features, medical and surgical approaches can undoubtedly be effective in relieving pelvic and abdominal pain. Length of treatment is arbitrarily set at six months. Symptomatic improvement should be evident by three months, since there is good evidence of substantial intracellular changes within the endometriosis lesions by then.12 What about ablative therapy at laparoscopy via either electrocautery or laser? A few groups have compared returns once are
this treatment with no treatment in infertile women, but no firm conclusions can be drawn about efficacy. There is a good case for initiating large randomised trials of these techniques. The pathogenesis of endometriosis still eludes us. The close similarity to endometrium suggests that the tissue is of epithelial origin, so implantation on the surface of pelvic organs probably occurs when menstrual blood refluxes down the fallopian tubes. Another possibility is that peritoneal mesothelium undergoes metaplasia to an endometrial-like epithelium. The importance of determining the correct mechanism will extend beyond the study of endometriosis per se since this condition is the only common "metastatic" disease that is benign. 1. Thomas EJ, Prentice A. The aetiology and pathogenesis of endometriosis. Reprod Med Rev 1992; 1: 21-36. 2. Jansen RP, Russell P. Non pigmented endometriosis: clinical, laparoscopic and pathologic definition. Am J Obstet Gynecol 1986; 155: 1154-59. 3. Nissole M, Paindaveine B, Bourdon A, et al. Histologic study of peritoneal endometriosis in infertile women. Fertil Steril 1990; 53: 984-88. 4. Vercellini P, Bocciolone L, Crosignani PG. Is endometriosis always a disease? Human Reprod 1992; 7: 627-29. 5. Audebert A, Backstrom T, Barlow DH, et al. Endometriosis 1991: a discussion document. Human Reprod 1992; 7: 432-35. 6. Bayer SR, Seibel MM, Saffan DS, Berger MJ, Taymor ML. Efficacy of danazol treatment for minimal endometriosis in infertile women. J Reprod Med 1988; 33: 179-83. 7. Telimaa S. Danazol and medroxyprogesterone acetate inefficacious in the treatment of infertility in endometriosis. Fertil Steril 1988; 50: 872-75. 8. Thomas EJ, Cooke ID. Impact of gestrinone on the course of asymptomatic endometriosis. BMJ 1987; 294: 272-74. 9. Telimaa S, Puolakka J, Ronnberg L, Kauppilla A. Placebo-controlled comparison of danazol and high-dose medroxyprogesterone acetate in the treatment of endometriosis. Gynecol Endocrinol 1987; 1: 13-23. 10. Mahmood TA, Templeton A. The impact of treatment on the natural history of endometriosis. Human Reprod 1990; 5: 965-70. 11. Evers J. The second look laparoscopy for the evaluation of the results of medical treatment of endometriosis should not be performed during ovarian suppression. Fertil Steril 1987; 47: 502-04. 12. Brosens IA, Verleyen A, Cornillie F. The morphologic effect of short term medical therapy of endometriosis. Am J Obstet Gynecol 1987; 157: 1215-21.
10. Brady MT, Evans J, Cuartas J. Survival and disinfection of parainfluenza viruses on environmental surfaces. Am J Infect Control 1990; 18: 18-23.
Endometriosis: time for reappraisal Endometriosis is the presence of tissue histologically similar to endometrium outside the uterine cavity and myometrium. The original of blue-black or "powder-burn" lesions, or ovarian cysts containing dark brown "chocolate" material. By causing an inflammatory reaction endometriosis precipitates pain and local damage that can ultimately lead to tubal occlusion or ovarian enclosure by fibrous tissue, and infertility. Until lately the condition was diagnosed only in those patients undergoing a laparotomy for a pelvic mass or pain. These women were a highly selected subgroup with an obvious mass or pain severe enough to warrant an invasive procedure, and the disease was perceived as uncommon. Use of laparoscopy early in the investigation of patients with infertility, pelvic or lower abdominal pain, and for sterilisation greatly enhanced our ability to inspect the pelvis and the new information generated has led to a reappraisal of
descriptions
were
endometriosis. Small lesions can be seen at laparoscopy in many women both with and without symptoms. The condition is commoner in those with infertility or the reported frequency in women being sterilised is risingi-an indication that doctors are increasingly sensitive to the diagnosis. Moreover, we now know that histological evidence of endometriosis can be found in many types of lesions other than the classic blue-black variety; for instance,endometriosis tissue has been found in over 50% of biopsy specimens from vesicular, haemorrhagic, and papular lesions, areas of fibrous scarring, and peritoneal defects.2 Histological evidence of endometriosis has even been found in up to 13% of peritoneal specimens that were apparently normal at biopsy.3 As a result of these observations some researchers have questioned whether endometriosis is a disease at all.4,5 If endometriosis is a common condition, visual diagnosis alone does not constitute a requirement to treat. The evidence that successful medical treatment of endometriosis in infertile women does not improve their fertility accords with this view.6,7 Although laparoscopic diagnosis of symptomless endometriosis is commoner in infertile women than in fertile controls, a group of European experts5 lately concluded that there can be no support for drug treatment of mild endometriosis in infertile women. Early reports of placebo-controlled trials suggested that the disease progressed in some patients and that, since progression was unpredictable, all patients should be treated.8 Subsequent studies showed that in over 50% of untreated patients the disease either improves or does not deteriorate/,1Q so there is little justification for such a therapeutic strategy. Furthermore, there is evidence that endometriosis
pain;
medical therapy is stopped-ie, the probably suppressing the disease rather than drugs it. 11 eradicating Thus, although endometriosis can unquestionably cause severe pelvic pain and destruction, lesions detected at laparoscopy may be incidental. It is therefore important to assess whether the patient’s symptoms are typical of endometriosis before attributing causality. Pain in endometriosis is usually cyclical and is precipitated by intercourse or defaecation. Physical signs such as a mass or tenderness are important confirmatory findings. In a patient with this constellation of features, medical and surgical approaches can undoubtedly be effective in relieving pelvic and abdominal pain. Length of treatment is arbitrarily set at six months. Symptomatic improvement should be evident by three months, since there is good evidence of substantial intracellular changes within the endometriosis lesions by then.12 What about ablative therapy at laparoscopy via either electrocautery or laser? A few groups have compared returns once are
this treatment with no treatment in infertile women, but no firm conclusions can be drawn about efficacy. There is a good case for initiating large randomised trials of these techniques. The pathogenesis of endometriosis still eludes us. The close similarity to endometrium suggests that the tissue is of epithelial origin, so implantation on the surface of pelvic organs probably occurs when menstrual blood refluxes down the fallopian tubes. Another possibility is that peritoneal mesothelium undergoes metaplasia to an endometrial-like epithelium. The importance of determining the correct mechanism will extend beyond the study of endometriosis per se since this condition is the only common "metastatic" disease that is benign. 1. Thomas EJ, Prentice A. The aetiology and pathogenesis of endometriosis. Reprod Med Rev 1992; 1: 21-36. 2. Jansen RP, Russell P. Non pigmented endometriosis: clinical, laparoscopic and pathologic definition. Am J Obstet Gynecol 1986; 155: 1154-59. 3. Nissole M, Paindaveine B, Bourdon A, et al. Histologic study of peritoneal endometriosis in infertile women. Fertil Steril 1990; 53: 984-88. 4. Vercellini P, Bocciolone L, Crosignani PG. Is endometriosis always a disease? Human Reprod 1992; 7: 627-29. 5. Audebert A, Backstrom T, Barlow DH, et al. Endometriosis 1991: a discussion document. Human Reprod 1992; 7: 432-35. 6. Bayer SR, Seibel MM, Saffan DS, Berger MJ, Taymor ML. Efficacy of danazol treatment for minimal endometriosis in infertile women. J Reprod Med 1988; 33: 179-83. 7. Telimaa S. Danazol and medroxyprogesterone acetate inefficacious in the treatment of infertility in endometriosis. Fertil Steril 1988; 50: 872-75. 8. Thomas EJ, Cooke ID. Impact of gestrinone on the course of asymptomatic endometriosis. BMJ 1987; 294: 272-74. 9. Telimaa S, Puolakka J, Ronnberg L, Kauppilla A. Placebo-controlled comparison of danazol and high-dose medroxyprogesterone acetate in the treatment of endometriosis. Gynecol Endocrinol 1987; 1: 13-23. 10. Mahmood TA, Templeton A. The impact of treatment on the natural history of endometriosis. Human Reprod 1990; 5: 965-70. 11. Evers J. The second look laparoscopy for the evaluation of the results of medical treatment of endometriosis should not be performed during ovarian suppression. Fertil Steril 1987; 47: 502-04. 12. Brosens IA, Verleyen A, Cornillie F. The morphologic effect of short term medical therapy of endometriosis. Am J Obstet Gynecol 1987; 157: 1215-21.
