Vaso di Pandora della terapia dell’endometriosi

Vaso di Pandora : la terapia dell'endometriosi Pandora’s box of endometriosis therapy Evidence based medicine Therapy in medicine should be based on evidence.  This is important to ascertain that a therapy is useful without side effects.  It protects the patient from practices without a proven benefit and reduces the cost of medicine. Evidence based medicine has developed a ranking of evidence known as the pyramid of evidence. This ranking is mathematically correct with the Randomised Controlled Trial on top. Randomisation avoid an allocation bias and ascertains that the 2 groups are identical. The limitations of a RCT A non blinded trial of pain therapy is not useful. The effect of a treatment should be evaluated without bias. This is obvious If the effect can be objectively measured as height or weight. For endpoints as pain or well being, there is the well know placebo effect and observer bias. RCT on pain and well being thus have to be double blinded to be valid. A RCT trial is not useful for complex multimorbidities. The results of a RCT are rue only for the group of women investigated and cannot be extrapolated. What can be a valid conclusion for 20 year old is not necessarily valid for a 60 year old. For this reason RCT are not suited for multi-morbidities. only Clinical observation can detect rare events. A RCT evaluates a group as a whole and cannot detect or exclude a (hidden) small subgroup with an opposite effect. Only after detection by clinical observation this can be evaluated by another RCT. The player Bias Treatment varies with the specialist in infertility...

L’atrofia vulvo-vaginale e la sessualità nelle donne in menopausa

L’atrofia vulvo-vaginale e la sessualità nelle donne in menopausa L’atrofia vulvo-vaginale  e la sessualità : : Come recuperare benessere e migliorare la  qualità di vita Cos’è la menopausa : la diminuzione della produzione di estrogeni Il 28 Marzo, al Senato, nella splendida Sala Giustiniani, si è tenuto un  Meeting di esperti su  un problema  molto importante della donna  in Menopausa, e di conseguenza della coppia: l’Atrofia Vulvo-Vaginale. La sessualità ed il piacere femminile, soprattutto dopo la menopausa e nella senilità , pur così importanti per il benessere fisico e psichico e la relazione di coppia   e quindi della qualità di vita  , sono stati in passato veri tabù ,argomenti che non venivano affrontati né dalle donne né dai medici  curanti, né dai ginecologi. Oggi si inizia a rompere  la barriera del silenzio  e a parlarne, per trovare una soluzione , ad un problema che affligge il 50% delle donne in Menopausa, e non solo delle donne dopo i 50 anni che hanno una menopausa fisiologica ma anche giovani donne che si trovano in menopausa indotta da terapie per il cancro o per l’endometriosi. Ho sentito la necessità di scrivere questo blog  come donna e come ginecologa perché ritengo che sia utile dare la giusta e corretta informazione su un problema vissuto per secoli con rassegnazione ed accettazione come conseguenza  fisiologica dell’avanzare degli anni o conseguenza  di una malattia “incurabile” come il cancro. La sessualità ed il piacere sono elementi indispensabili al benessere psico fisico di uomini e donne e di conseguenza  della coppia. Ma cos’è l’atrofia vulvo- vaginale :  la vagina senza estrogeni Come ben espresso dalla professoressa Rossella...

Chirurgia per idronefrosi cronico

Chirurgia per idronefrosi cronico In response to a question : how to treat silent hydronefrosis (without pain) and a marked reduction in kidney function ? AAGL-ENDO-EXCHANGE Digest - 7 Aug 2011 to 8 Aug 2011 Date: Mon, 8 Aug 2011 15:50:26 -0400 From: Philippe Koninckx and Anastasia Ussia <Gary_Frishman@BROWN.EDU> Subject: Chronic hydronephrosis surgical management In all cases seen with hydronephrosis until today (around 100): strategy has been consistently the same * insert a stent if possible * dissect the ureter what will give the diagnosis of the cause of the hydronephrosis ie generally endometriosis, rarely compression only. Anyway this becomes apparent during dissection. * during dissection decide whether excision of surrounding endometriosis is sufficient or whether a resection anastomosis is necessary (a reimplantation almost always is a secondary option after failure as published) Since dissection of the ureter was not done, I would suggest repeat surgery. The prognosis of the kidney function is difficult to predict since the duration that the hydronephrosis existed is unknown. Sincerely Philippe Koninckx and Anastasia Ussia Gruppo Italo Belga, Belgium and...

idronefosi, resezione intestinale inutile e endometriosi profonda

idronefosi, resezione intestinale inutile e endometriosi profonda per vedere la discussione completa in inglese AAGL-ENDO-EXCHANGE Digest - 28 Dec 2010 to 29 Dec 2010 (#2010-156)Date: Wed, 29 Dec 2010 20:00:34 -0500 From: Philippe R Koninckx Subject: 31 y.o. with firm rectovaginal mass and intermittent hydronephrosis To the ongoing discussion we would like to add some remarks, backed up with direct links to the articles referred to. 1. We fully agree with David Redwine that this lady needs surgical excision of all deep endometriosis. It is unclear whether LHRH agonists may be usefull. We do not recommend this since we have the impreesion that planes of cleavage become more difficult. 2. We do consider it a mistake to do IVF in a woman with a rectovaginal nodule as presented at the ESGE meeting in Amsterdam 2008. 3. In addition if the hydronefroses would not regress during an eventual pregnancy, it will become a painful decision what to do.(as I saw once) 4. We stronly oppose the concept of at team is required to treat the ureter. First for the lower ureter as written in Fertil steril last year ( http://www.gynsurgery.org/ols/pdf/2009_decicco_ureter.pdf ) any lesion can be treated conservatively and ureter reimplantation has no place anymore as a first line of treatment. Since in Europe mainly gynaecologists have the required skills and expertise for an eventual ureter reanastomosis, we recommended that the lower ureter should be considered part of gynaecology. Anyway the patient should be informed about the available skills otherwise informed consent cannot be obtained. ( http://www.gynsurgery.org/hysterectomy-myomectomy/surgical-mistakes-and-surgical-quality/ ) 5. In over 2000 deep endometriosis excisions of the rectum or rectosigmoid, a...

Consento Informato ed isterectomia

Consento Informato ed isterectomia Published on AAGL listserv Date: Mon, 29 Nov 2010 20:59:15 -0500 From: “Philippe R. Koninckx and Anastasia Ussia” <Gary_Frishman@BROWN.EDU> Subject:Informed consent and medicolegal exposure . Reading the last exchange of ideas, it seems important not to mix several issues. 1. Open hysterectomy versus laparoscopic hysterectomy. This is difficult to understand, given the legal obligation to obtain informed consent, which implies explaining the intervention and the alternatives. In Belgium, the latter moreover is obligatory. With the available evidence today, it seems highly unlikely, that any patient being explained the pro’s and cons will choose for open hysterectomy. If the alternatives were not explained and performs an open hysterectomy, the surgeon exposes himself to medico-legal action. 2. Robotic surgery. For a debate at the ESGE in Barcelone this year we reviewed the literature. Today there is no proven benefit in gynaecology, nor to the best of our knowledge in other disciplines. The increased costs associated with robotic surgery, however are obvious. 3. Tubal sterilisation. Important in this discussion is the often forgotten aspect of maintaining the possibility of reversal eg with Yoon ring or clips Philippe R. Koninckx and Anastasia Ussia Universities of Leuven, Belgium, Oxford UK and Rome Italy Gruppo Italo Belga, Rome...

endometriosi e bisfenolo

endometriosi e bisfenolo Recammente, nella stampa Italiana, il bisfenolo a considerata come la causa dell’endometriosi. 1. La relazione tra endometriosi e ‘endocrine disrupters’ ha inizio nel 1994 con un articolo di Koninckx seguito dall’articolo di Rier. Fino a oggi non è chiaro  se  vi è o meno questa  relazione . Suppratutto e inutile fare paura alle donne. 2.. Anche la storia del bisfenolo – un altro endocrine disrupter della  stessa famiglia- è gia vecchia e inizia con un bell’ articolo di Tsutsumi. e l’articolo di Newbold et al, 2005 . Come demonstrato prima per tanti altre estrogeni (stilbestrol e estogeno-like ) una dose forte supranormale puo creare problemi nel sviluppo genitali. Come dimostrato precedentemente  per tanti altre estrogeni (stilbestrol ed estogeno-like ) una  fortissima  dose può creare problemi nel sviluppo genitali. Il primo articolo nelle donne con endometriosi è di 2009 dimostrando che le donne con endometriosi hanno una  concentrazione di bisfenolo piu alto nel sangue. Non era chiaro se le concentrazioni erano sufficiente per far sviluppare un’endometriosi. 3. I dati recenti Signorile et al 2009 trovano ‘endometriosis-like lesions’ nelle topi.  Dal momento che non è chiaro  se queste lesiooni siano endometriosi, abbiamo (Ronald E. Batt, University at Buffalo, State University of New York, USA ,Lone Hummelshoj, Endometriosis.org, London, England,Charles Chapron, Université Paris Descartes, CHU Cochin, Paris, France ,Dan C. Martin, University of Tennessee Health Science Center, Memphis, USA, Glenna C. Bett, University at Buffalo, State University of New York, USA, John Yeh, University at Buffalo, State University of New York, USA, Philippe R. Koninckx, KULeuven Belgium; University of Oxford, UK; and Università Cattolica, Roma, Italy) gia scritto un...

Shiny Trinket

Shiny trinkets are shiny.