Current Women's Health Reviews - Volume 8, Issue 2, 2012

In this issue there is a combined effort of four European Departments of Gynecological Health in Greece, Romania and Scotland to approach the very interesting and still under research issue of endometriosis. In the beginning, N. Tsabazis try to give us an overview of pathogenesis and pathophysiology. Although pathogenesis and the mechanisms of pathophysiology are still debatable, the author manages to give us up to date knowledge about modern theories which uncover the important role of genetics and immune system. The ongoing immunological research will most probably shed more light to the numerous components in order to enable researchers to consider a holistic approach to the pathophysiology of the disease, making use of all the knowledge gathered so far. We are grateful to C. Sardeli, a specialist in the field of pharmacology. In her article she discusses the general principles on which classic and novel approaches in the pharmacotherapy of endometriosis are based and presents the classes of drugs involved. In conclusion, currently available pharmacotherapies are still not curative but symptomatic and aim either at decreasing ovarian estrogen production or at antagonizing estrogen action. Recurrence is the rule after cessation of treatment and pharmacotherapies are not suitable for women seeking conception....

Objective: This overview is aimed to summarize the pathogenic theories of endometriosis and to relate them to the various disease localizations and secondly, to sketch a pathophysiology model for the disease progress, namely the development of pain syndromes and subfertility. Materials-Methods: A yield of articles and reviews in Medline using key words in various combinations such as endometriosis, inflammatory mediators, oxidative stress, pathogenesis, pathophysiology, infertility, immunity, theory, pain, mullerianosis disease, and peritoneal reaction, has been reviewed and shortlisted on the basis of their reference to a particular pathogenesis mechanism or relation to pain and infertility. Results: An attempt to synthesize the collected information in an orderly manner has reinforced the notion of a holistic approach in the pathogenesis of the disease. “Endometriosis” is a rather collective term encompassing different disease entities. All mechanisms of pathogenesis may contribute in different combinations according to the disease phenotype. The same is true for the variety of pathophysiology mechanisms leading to pain syndromes and infertility, the two major components of the disease expression. Conclusion: The key issue in management is to recognize the multifactorial aspect of the disease in each case scenario before planning a therapeutical intervention.

Objective: To assess any possible adverse effects of endometriosis on pregnancy outcome and complications, as well as in the postpartum period. Study Design: A systematic review of the literature. Data Sources: We searched all publications in Pubmed, Scopus and the Cochrane Library with the key words endometriosis, pregnancy outcome, preeclampsia, preterm birth, small-for gestational age babies (SGA) and postpartum. Eligibility Criteria for Selecting Studies: All studies reporting on endometriosis and perinatal outcome until December 2009. Results: According to the available bibliographic data, we found 38 reported cases of pregnancies, four being twin pregnancies, complicated by endometriosis (Table 1). Studies referring to specific pregnancy complications (preterm birth, small-for-gestational age babies, preeclampsia and postpartum complications) were limited to a total of 12 publications [61-63, 69, 75, 80, 82-86]. The few reported complications during pregnancy included hemoperitoneum and spontaneous bleeding [1, 9-21], perforations of the jejunum, appendix and sigmoid colon [22-24], urohemoperitoneum [25], deciduosis of the appendix [26], deciduosis of the omentum [27], infected endometrioma [28], hemoperitoneum and hemothorax [29], catamenial pneumothorax [30], endometriosis imitating a bladder tumor [31], decidualization mimicking ovarian malignancy [32], rupture of ovarian endometriotic cyst [23, 33], and rupture of the uterus affected by endometriosis [34] (Table 1). Data regarding the effect of endometriosis on preterm birth, small-for gestational age babies and preeclampsia, both in spontaneous pregnancies as well as in those conceived by Assisted Reproductive Techniques (ART) were conflicting. Conclusions: Symptoms of endometriosis often disappear during pregnancy. Yet, endometriosis must be included in the differential diagnosis of hemoperitoneum presenting during pregnancy or of heavy vaginal bleeding postpartum. Both maternal and fetal morbidity and mortality can be quite high and the woman’s childbearing ability might be irreversibly affected. The few available data on the association between endometriosis and preeclampsia are at present controversial. Together with the studies reporting an increased risk for preterm birth in women with endometriosis, physicians must be aware that close antenatal follow-up and early diagnosis is crucial. Postpartum manifestations of endometriosis, although extremely rare, can give rise to severe complications with a high possibility of irreversibly affecting the woman’s childbearing ability.

Objective: We review the surgical modalities used in the treatment of endometriosis, including ablative, excisional and denervating. Design: A systematic review of the literature referring to the surgical treatment of endometriosis with emphasis on articles published since 2000. Data sources: Medline, MeSH and Cochrane library searches for terms including “endometriosis”, “ablation”, “excision”, “denervation”, “pelvic pain” and “infertility”. Eligibility criteria: Trials assessing the short, medium and longer-term efficacy of surgical modalities employed in the treatment of endometriosis were considered. Studies published prior to 2000 and small power trials were included only if commonly referenced in the literature. Results: 114 articles were considered with 53 referenced in the final review. Conclusions: Excisional treatment provides more favourable outcomes than drainage and ablation with regards to pain relief, endometrioma recurrence, symptom control and fertility rates. Ancillary surgical procedures such as presacral neurectomy and laparoscopic uterine nerve ablation can prove helpful in the management of dysmenorrhoea. Radical surgery in the form of hysterectomy remains end-stage treatment for endometriosis. The role of medical treatment remains unclear.

Objective: This review discusses the general principles on which classic and novel approaches in the pharmacotherapy of endometriosis are based and presents the types of drugs involved. Design: Review article. Data sources: Relevant studies were retrieved from Pubmed, Scopus and ISI -Web of knowledge databases. Eligibility criteria: All articles in English, French, German and Danish languages that contained the following keywords: endometriosis, pharmacotherapy, pain relief, chronic pelvic pain & infertility, were retrieved and read and all relevant data were included in this review. Results: Endometriosis is an estrogen-dependent, benign gynaecologic disorder, characterized by the presence of tissue morphologically and biologically similar to normal endometrium outside its normal location. The underlying aetiology and pathophysiology are poorly understood. Dyspareunia, dysmenorrhea, chronic pelvic pain and infertility are characteristic and debilitating manifestations of the disease. Several pharmacotherapeutic approaches are available. Currently available pharmacotherapies are not curative but symptomatic and aim either at decreasing ovarian estrogen production or at antagonizing estrogen action. Recurrence is the rule after cessation of treatment while pharmacotherapy is not suitable for women seeking conception. Conclusions: No curative pharmacotherapeutic options for treating endometriosis are currently available and most options complicate the course of treatment due to adverse events and short-term results. Novel approaches aim to take advantage of recent advances in endometriosis research but limited data are available regarding chronic use and long-term safety and efficacy.

Objective: Endometriosis has been suspected of playing a role in the etiology of ovarian cancer. Design: This systematic review addresses the parallels and specific relationship of endometriosis and gynecological cancer regarding risk factors, histological data, genetic alterations, aberrant activation of oncogenic and antiapoptotic pathways, and options in clinical diagnosis. Data sources and eligibility criteria: We have performed a Pubmed search looking for all articles in English, using as key words “endometriosis”, “ovarian cancer”, “gynecologic cancer”, “pathogenesis”. Results: The evidence of the published studies suggests that ovarian tumors can arise from more than one potential source, endometriosis being one of these sources. Conclusion: Understanding the mechanism of the development of endometriosis and elucidating its pathogenesis and pathophysiology are intrinsic to the prevention of endometriosis associated ovarian cancer and the search for effective therapies.

The purpose of this article is to review the current knowledge, and recommendations for screening infectious diseases during pregnancy to improve maternal, fetal and newborn health. We examined studies and public health policies published in English language to identify which tests and in which situations recommendations are being made. Universal prenatal screening with at least one test for syphilis, human immunodeficiency virus, and asymptomatic bacteriuria is largely recommended. Approaches for maternal screening for preventing perinatal transmission of the Hepatitis B virus are not uniform and early vaccination of newborns irrespective of maternal screening is frequently adopted in resourcelimited countries. Screening for maternal Hepatitis C infection can be considered for high-risk women. Routine screening for Cytomegalovirus is not usually recommended by public health authorities but is being debated among experts. Universal screening for Group B Streptococcus at 35-37 weeks gestation is the preferred approach for preventing neonatal disease. Selective early gestation Chlamydia trachomatis and Neisseria gonorrhea screening of pregnant women based on risk factors is performed in developed countries. Although prenatal testing for Toxoplasma gondii is routinely offered in some countries, no consensus exists about the benefits, diagnostic tests or the most effective screening strategy to prevent congenital toxoplasmosis.

In the developing countries, an estimated 2.5 million children under the age of 15 were living with HIV in 2009, and there were some 370 000 new HIV paediatric infections. Nearly all of these new infections could have been avoided with effective prevention of mother-to-child transmission (PMTCT) interventions. Any intervention dispensed with, mother-to-child transmission (MTCT) rates range from 15-30% without breastfeeding to 30-45% with prolonged breastfeeding. In developing countries, where elective caesarean section and breastfeeding avoidance are generally unsafe or unaccepted options, antiretroviral drugs (ARVs) have been documented to reduce MTCT to 2% or below. Even though substantial achievements were recently reported in PMTCT in implementing Sub-Saharan Africa highburden countries, much more has quickly to be done to virtually eliminate MTCT of HIV by 2015. To this aim, plenty of commitment and coordinated action by all involved parties, including the private sector, are needed. The challenges and critical points bound-up with the desired PMTCT outcomes are discussed in this review, in the light of 2010 revised WHO recommendations for PMTCT in low-income HIV settings. They recommend HIV-infected pregnant women to start ARV therapy for their own health at CD4 cell count ≤ 350/mm3. Additionally, they promote the use of ARVs for prophylaxis earlier in pregnancy, beginning at 14 weeks and continuing through the end of breastfeeding period. Moreover, in countries where breastfeeding is judged to be the best option, HIVinfected mothers (whose infants are uninfected or unknown status) are recommended to continue breastfeeding for the first 12 months of life, provided they are taking ARVs during that period.

Recurrent cystitis is common among pre-menopausal, healthy, non-pregnant women. Each episode of urinary tract infection (UTI) results in loss of working hours and quality of personal life. Most of recurrent UTIs are caused by uropathogenic Escherichia coli (UPEC). Its infectivity is in part due to the acquisition of pilli with an adhesin for mannose-containing receptors of the bladder. UTI-prone women are believed to have a compromised immune response, so even after a successful resolution of the infection reinfection is common. Many risk factors contribute to recurrence of UTI, including frequency of intercourse, new sex partners, diaphragm use, and age of first UTI. Pivmecillinam, nitrofurantoin, trimethoprim/ sulfamethoxazole, and fofomycin are considered first-line agents against cystitis. Short-term 3-day antibacterial regimens with quinolones are used as second-line agents in order to prevent emergence of antimicrobial resistance to them. Low doses of any of the aforementioned antibacterials can be used for prophylaxis against recurrences. An immunostimulant extracted from 18 heat-killed Escherichia coli strains of 5 different serotypes (URO-VAXOM), given orally once daily for 3 months has been tested and shown to have good efficacy for prophylaxis of recurrent UTIs. Cranberry products are also effective for prophylaxis, however with high rates of withdrawal. Oral Dmannose can bind pilli and their adhesin, which are essential for binding, invasion and formation of biofilm, however more clinical data are needed to support its use. Probiotics are the second most tested prophylactic agents after antibiotics; their efficacy varies according to the type of administered probiotic.