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Pandora’s box of endometriosis therapy

Pandora's box of endometriosis therapy   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 medical...

Premenstrual syndrome

Premenstrual syndrome PMS - endometriosis   PMS or premenstrual syndrome and endometriosis A recent question by a patient prompted us to review premenstrual syndrome(1-4). The traditional view Premenstrual syndrome is a frequent, well known (4500 hits on pubmed) but poorly understood syndrome, occurring to some extend in most if not all women in the premenstrual period . The symptoms of PMS are variable. Some women have mainly brain symptoms or premenstrual dysphoric disorder with feelings as irritability, depression, mood swings, nervousness, irritation, sleep disturbances, character changes and more severe psychiatric syndromes. Other women mainly complain  of  ‘progesterone’ effects  as abdominal bloating, water retention and breast tenderness. Traditional gynecology and endocrinology consider progesterone concentrations or hormone changes  as the driving motor of PMS. It seems logical since PMS occurs in the luteal phase of an ovulatory menstrual cycle. The ‘classic’ but empirical treatment with progesterone orally or intra-vaginally,  unfortunately is not very effective. Even the suppression of ovulation is not that effective according to a recent Cochrane review (5). What is missing in the literature ? Traditional gynecology and endocrinology do not consider clinical observation as valuable information. When Evidence Based Medicine becomes a religion what is not proven -preferentially in a RCT-  does not exist.  We recently discussed this in detail for surgery(6). After 30 and 40 years of gynecologic endocrinology and endometriosis we consider important for PMS The effect of age : in young women severe PMS is rare; it increases with age and decreases after 45 years The importance of an uterus : severe PMS is extremely rare in the absence of a uterus even in women...

Endometriosis symptoms checklist

Endometriosis symptoms checklist Aim is a simple symptoms check-list to answer the following questions when should I look for help ? which is the probability of typical-cystic-deep endometriosis with my symptoms ? when to doubt/correct my GP or gynecologist and ask for a second opinion ? Endometriosis might be present = diagnosis required depending on the severity of symptoms diagnosis= laparoscopy for cystic ovarian endometriosis diagnosis is laparoscopy for superficial and deep endometriosis No complaints : typical lesions in 5%, occasionally cystic and deep Only dysmenorrhea If severe : typical in 50% if very severe : cystic in 10% ; deep in 5% Chronic pelvic pain If severe ; typical in 50% , cystic ovarian in 10% if very severe : cystic ovarian 15% ; deep 5 % however many other causes that can cause chronic pelvic pain have to be ruled out Only infertility typical lesion will be found in 50% Diagnosis for endometriosis required Radiation of pain to the anterior-inside of the upper leg = ovarian pain perineal pain radiation is pathognomonic for deep endometriosis dyschesia during menstruation and/or diarrea during menstruation suggests deep endometriosis dysuria at the end of micturition can suggest deep endometriosis of the bladder Common mistakes A normal clinical exam or ultrasound or MRI does not rule out even severe endometriosis Menorrhagia or menstrual disturbances might be present in endometriosis, but do not suggest endometriosis Medical therapy for endometriosis without a diagnosis unless for a short period of time Comments A laparoscopy unfortunately is invasive : therefore the indication is finally made by a clinician with experience. this reflects the questions before an...

Surgeons Guidelines : Diagnosis and treatment of deep endometriosis

Deep endometriosis Guidelines by surgeons 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.