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...

Endometriosi e sessualità

Endometriosi e sessualità Endometriosi colpisce la donna 6 volte Endometriosis and sexuality The perception is biased Numerous articles describe sexual problems in women with endometriosis. The perception of a causal relationship between endometriosis and sexuality and pain during intercourse however is highly biased and more often wrong than right. The 6 insults to the sexual life of women with endometriosis and the 6 mistakes Pain during intercourse due to endometriosis It is well established, and clinically obvious that a deep endometriosis nodule between vagina, uterus and bowel can cause severe pain during intercourse. It also is clear that cystic ovarian endometriosis, especially when situated low in the pouch of Douglas can cause pain during intercourse (1-4). Also typical lesions in the utero-sacral ligaments can cause discomfort. This pain is reproduced by clinical exam and during ultrasound (5) otherwise the diagnosis is wrong. This obviously affects endometriosis and sexuality. Mistake 1 : A frequent mistake is the conclusion that pain during intercourse is caused by endometriosis when in a women with subtle or typical endometriosis, the pain during intercourse cannot be reproduced during gynaecological exam or transvaginal ultrasound exam. It is highly unlikely that this pain is caused by endometriosis. Pain during intercourse not due to endometriosis There are many other reasons for pain during intercourse such as introital pain, hymenal pain, pain in the episiotomy scar or in another vaginal scar, pain due to a retro-flected uterus and sometimes adenomyosis. In addition pain the abdominal wall, and sceletal pain (sacro ileac joint) after intercourse are often described as sexual pain. Mistake 2 : not performing a thorough exam to...

Marcatori dell’endometriosi

Marcatori dell'Endometriosi For English Marcatori dell’endometriosi Una perdita di tempo e denaro ? La ricerca di marcatori o endometriosi non invasivi rimane un problema. Il servizio costa un sacco di soldi la ricerca e l’energia, che -per quanto di mia conoscenza è uno spreco di tempo e denaro. Anzi, non mi aspetto una svolta in un lasso di tempo ragionevole, nonostante gli sforzi investiti. Il fatto che così tanti ricercatori investono tanta fatica e il denaro è intrigante. Qualcuno deve fare un errore. Quindi una breve discussione o gli argomenti pro e contro sembra appropriato. Gli argomenti pro Teoricamente sarebbe bello avere un esame del sangue marcatore e semplice da diagnosticare l’endometriosi. Si potrebbe risolvere il problema del ritardo nella diagnosi. Forse la diagnosi precoce (e terapia) potrebbero impedire la progressione verso una forma più grave. Un marcatore per l’endometriosi avrebbe permesso di dare terapia medica, senza la necessità di fare una laparoscopia per la diagnosi e per evitare l’intervento chirurgico. Tale test o marker per endometriosi sarà anche una macchina per fare soldi. Prima sarà massicciamente utilizzato in tutte le donne con dolore pelvico, anche un po dismenorrea, e / o infertilità. In secondo luogo, amplificherà la terapia medica, che sarà dato per prevenire la progressione. Questa affermazione però si basa su prove molto deboli e prive di fondamento. La argomenti condizionata e gli errori Senza definire quale tipo di endometriosi, un marcatore non è utile ‘Un marcatore per l’endometriosi’ suona bene. Tuttavia, l’uso della parola endometriosi (volutamente) si nasconde quel sottile, tipica, cistica e l’endometriosi profonda sono diverse patologie. Si presuppone che l’endometriosi è una malattia progressiva....

Terapia medica prima o dopo la chirurgia

Terapia medica prima o dopo la chirurgia per endometriosi Guidelines da chirurgi What is different in comparison with ESHRE guidelines below (1) Medical therapy Before surgery Facts Medical therapy for endometriosis suppresses ovarian function. The lack of estrogens inactivates endometriosis lesions (as after menopause)  or the high doses of progestogens will decidualize (as during pregnancy) them. Subtle and probably other lesions (typical, smaller cystic or some deep)  thus risk to be missed since less visible. Cystic ovarian endometriosis will sometimes decrease slightly in volume. Deep endometriosis will shrink and probably becomes less vascularized. Potential Benefits The absence of ovulation and of a corpus luteum can be a surgical advantage.  A corpus luteum indeed bleeds easily when touched during ovarian surgery  with subsequent risks of ovarian damage by coagulation and later adhesion formation. There should be less confusion between a cystic corpus luteum and  cystic ovarian endometriosis. Practically however, a cystic corpus luteum can persist for more than 6 months under oral contraception. Adverse effects Subtle and typical lesions risk to be missed during surgery. Thus the diagnosis is not made and so is the excision. Cystic ovarian endometriosis . Smaller lesions might be missed. Surgical excision of  is not facilitated by medical therapy. Deep endometriosis grows irregularly and common sense suggest that excision could be incomplete since extensions are missed. Appendicular endometriosis risks to be missed. Conclusions Medical therapy before endometriosis surgery lesions risk to be missed surgery risks to be incomplete no surgical advantage Conclusion: should not be given Solid evidence that lesions risk to be missed do not exist since it is impossible to demonstrate this in...

Guidelines da chirurgi : diagnosi e trattamento dell’endometriosi profonda

Endometriosi profonda Guidelines da chirurgi Diagnosis of deep endometriosis The final diagnosis of a deep endometriosis nodule -defined as adenomyosis externa- is made during surgery. Confirmation by pathology is close to 100%. After previous surgery, however , it can be difficult to distinguish deep endometriosis from fibrosis. Deep endometriosis should be suspected in all women with severe menstrual pain, especially severe dyschesia, mictalgia , deep dyspareunea and pain with perineal radiation. The diagnostic accuracy of exams varies with the size and the localisation of the deep endometriosis nodule. Clinical exam will obviously diagnose 100% of vaginally visible nodules if the clinician has experience. Otherwise, clinical exam will diagnose only 50% (1) to 90% of recto-vaginal nodules . A clinical exam cannot exclude a deep endometriosis nodule. Although CA125 has a specificity and sensitivity of 90% when assayed during the first days after menstruation, it was not considered a useful clinical tool for the diagnosis of deep endometriosis (1). Ultrasound is reported to have a sensitivity and specificity of 90 to over 95% for recto-vaginal and recto-sigmoid nodules. Accuracy moreover is operator dependent. Although the accuracy for small nodules is not known the accuracy obviously is less. A negative ultrasound exam therefore cannot exclude a small and/or a high situated or sigmoid nodule. MRI has a similar sensitivity and specificity as ultrasound and is less operator dependent. Since the accuracy for small nodules and the lower detection limit has not been established a negative exam cannot exclude a deep endometriosis nodule. Approved by Surgeons. Stephan Gordts, Life Expert Centre, Leuven, Belgium, Errico Zupi Prof Univ Tor vergate, Rome Italy, Anastasia...

Shiny Trinket

Shiny trinkets are shiny.