今日の臨床サポート

子宮内膜症

著者: 北脇 城 京都府立医科大学 産婦人科

監修: 杉野法広 山口大学 産科婦人科学

著者校正/監修レビュー済:2021/11/10
参考ガイドライン:
  1. 日本産科婦人科学会編:子宮内膜症取扱い規約 第1部、東京、金原出版、1993.
  1. 日本産科婦人科学会:子宮内膜症取扱い規約 第2部診療編第3版、金原出版、2021.
  1. 日本産科婦人科学会日本産婦人科医会.産婦人科診療ガイドライン:婦人科外来編2020、2020.
  1. European Society of Human Reproduction and Embryology: Guideline on the management of women with endometriosis, 2013(https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline)
患者向け説明資料

概要・推奨   

  1. 子宮内膜症性疼痛は、少なくとも月経痛、慢性骨盤痛、性交痛に分類して問診する。疼痛の程度はvisual analog scale (VAS)によって評価する(推奨度1)。
  1. 子宮内膜症の確定診断は腹腔鏡検査によって直視的に行うことが原則である(推奨度1)。
  1. 不妊を訴える患者のうち「臨床子宮内膜症」と診断された場合には、腹腔鏡下手術が第1選択となる(推奨度1)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となり
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧には
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要と
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
北脇 城 : 未申告[2021年]
監修:杉野法広 : 研究費・助成金など(浜田市,あすか製薬)[2021年]

改訂のポイント:
  1. 日本産科婦人科学会.子宮内膜症取扱い規約 第2部診療編第3版の出版に基づき、主に卵巣子宮内膜症性嚢胞の取り扱いに関して若干の改訂を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 子宮内膜症とは、子宮内膜またはその類似組織が子宮以外の部位で増殖、発育し、機能する疾患である。
 
子宮内膜症

出典

 
  1. 発生機序は、Sampsonの子宮内膜移植説、体腔上皮化成説、胎児組織遺残説、あるいはこれらを複合した説が提唱されているが、未だに不明である。
  1. 第一親等における発生が5~8%である[1]。多くのcommon diseaseがそうであるように、遺伝的素因をもつ個体に後天的な環境要因が加わって疾患が発生する多因子疾患と考えられている。
  1. 性成熟期女性の約10%が罹患する良性の慢性疾患であり、エストロゲン依存性に増殖する。妊娠により改善し、閉経または卵巣摘出術により退縮する。
  1. エストロゲン依存性疾患である子宮腺筋症や子宮筋腫としばしば合併する。
  1. 腹膜病変、卵巣子宮内膜症性嚢胞(卵巣チョコレート嚢胞)、深部病変、癒着などを形成する。
 
子宮内膜症の病変

子宮内膜症の病変は、大別して腹膜病変、卵巣子宮内膜症性嚢胞(卵巣チョコレート嚢胞)、深部病変があり、周辺組織と癒着を形成する。

出典

img1:  著者提供
 
 
 
  1. 主症状は、月経痛、下腹痛、性交痛などの慢性骨盤痛と、不妊である。
問診・診察のポイント  
  1. 子宮内膜症患者のうち88%が月経困難症を訴え、そのうち70%が鎮痛剤を必要とするほどの強い疼痛を有する[2]
  1. 月経時以外の下腹部痛・腰痛は46%、性交時痛・排便痛は30%と、慢性骨盤痛は高頻度に認められる[2]
  1. 不妊は30~60%に認められる。しかし、自覚症状と病巣の重症度とが比例しないことが特徴である。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

詳しくはクリック
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

著者: Joe Leigh Simpson, Farideh Z Bischoff, Aparna Kamat, John E Buster, Sandra A Carson
雑誌名: Obstet Gynecol Clin North Am. 2003 Mar;30(1):21-40, vii.
Abstract/Text Endometriosis long has been recognized as showing heritable tendencies, with recurrence risks of 5% to 7% for first-degree relatives. The risk indicates that polygenic and multifactorial etiology is far more likely to be the cause than mendelian inheritance. The current task is to determine the number and location of genes responsible for endometriosis. Molecular advances of the past decade make identification and elucidation of these genes a reality. The authors review the basis for concluding that endometriosis is a genetic disorder of polygenic/multifactorial inheritance. Genome-wide strategies for identifying causative genes are considered and available data on association or linkage to putative candidate genes systematically reviewed.

PMID 12699256  Obstet Gynecol Clin North Am. 2003 Mar;30(1):21-40, vii・・・
著者: Jo Kitawaki, Hiroaki Ishihara, Hisato Koshiba, Miyo Kiyomizu, Mariko Teramoto, Yui Kitaoka, Hideo Honjo
雑誌名: Hum Reprod. 2005 Jul;20(7):1999-2003. doi: 10.1093/humrep/deh890. Epub 2005 May 12.
Abstract/Text BACKGROUND: The aim of this study was to evaluate the diagnostic significance of CA-125 for endometriosis without ovarian endometriomas.
METHODS: Preoperative serum CA-125 levels were measured in 775 consecutive women diagnosed by laparoscopy or laparotomy with endometriosis, adenomyosis, leiomyomas, or normal pelvis.
RESULTS: Receiver operating characteristic curve analysis revealed that the area under the curve for endometriosis without endometriomas was 0.788, significantly smaller than that for endometriosis with endometriomas (0.935, P < 0.05). In diagnosis of endometriosis without endometriomas, both the maximal accuracy of 78.8% and the maximal diagnostic value of 61.2% were obtained at the cutoff value of 20 U/mL. Negative predictive value was 78.0% at the cutoff value of 20 U/mL, whereas positive predictive value was 92.9% at the cutoff value of 30 U/mL. This range is clearly superior to the empirical single cutoff of 35 U/mL.
CONCLUSIONS: In the diagnosis of endometriosis without endometriomas, combined use of two cutoff values for CA-125, 20 and 30 U/mL, provides improved diagnostic performance. However, the accuracy of using only CA-125 testing for diagnosis is still limited. Serum CA-125 testing can be done during initial screenings of women with possible endometriosis.

PMID 15890727  Hum Reprod. 2005 Jul;20(7):1999-2003. doi: 10.1093/humr・・・
著者:
雑誌名: Fertil Steril. 1997 May;67(5):817-21.
Abstract/Text
PMID 9130884  Fertil Steril. 1997 May;67(5):817-21.
著者: J D Seidman
雑誌名: Int J Gynecol Pathol. 1996 Jan;15(1):1-9.
Abstract/Text Endometriosis occasionally exhibits cytologic atypia in the lining of endometriotic cysts or hyperplasia resembling uterine endometrial hyperplasias, but the risk of development of adenocarcinoma in these patients is unknown. A total of 105 women with endometriosis were studied: 37 with cytologic atypia (usually in the lining of endometriotic cysts), 34 with hyperplasia resembling uterine endometrial hyperplasia, and 34 controls. For lesions resembling eutopic endometrial hyperplasia, the Kurman-Norris criteria for separating atypical hyperplasia from well-differentiated endometrial adenocarcinoma were used to subdivide this group into 23 complex atypical hyperplasias and 11 "early carcinomas." Some 62 women were successfully followed for a mean of 8.7 years. One patient with early carcinoma developed a poorly differentiated endometrioid adenocarcinoma at the vaginal apex 8.1 years later. A second patient with early carcinoma developed a mullerian mucinous tumor of low malignant potential in the contralateral ovary 7 years later. Both of the latter two patients had multifocal endometriosis. Except for persistent benign endometriotic lesions in four patients, and breast carcinoma in one, all remaining patients were alive and well at last contact. It is concluded that the Kurman-Norris criteria for eutopic endometrial adenocarcinoma may be useful in identifying rare patients with endometriosis in whom there may be an increased risk of neoplastic transformation of their endometriosis.

PMID 8852439  Int J Gynecol Pathol. 1996 Jan;15(1):1-9.
著者: H Kobayashi, K Sumimoto, N Moniwa, M Imai, K Takakura, T Kuromaki, E Morioka, K Arisawa, T Terao
雑誌名: Int J Gynecol Cancer. 2007 Jan-Feb;17(1):37-43. doi: 10.1111/j.1525-1438.2006.00754.x.
Abstract/Text Although some studies have indicated that endometriosis may increase the risk of developing ovarian cancer, there are no data from epidemiologic studies in Japan. We prospectively analyzed all cases of ovarian endometrioma enrolled in the prefecture-wide Shizuoka Cohort Study on Endometriosis and Ovarian Cancer Programme, which was initiated in 1985. To evaluate the risk of ovarian cancer by time periods subsequent to ovarian endometrioma diagnosis, a cohort of 6,398 women with a clinically documented ovarian endometrioma in Shizuoka between 1985 and 1995 was identified from the Shizuoka Cancer Registry (SCR), with follow-up through 2002. Ovarian cancer incidence among cohort members was ascertained by linkage to the SCR using a unique person-identification number. Standardized incidence ratios (SIR) and their 95% confidence intervals (CI) were computed by a use of prefecture-wide rates of ovarian cancer, adjusted for age and calendar year. During follow-up of up to 17 years of the ovarian endometrioma cohort, 46 incident ovarian cancers were identified, yielding that the ovarian cancer risk was elevated significantly among patients with ovarian endometrioma (SIR = 8.95, 95% CI = 4.12-15.3). The SIR did not increase with increasing follow-up duration. The risk increased with increasing age at ovarian endometrioma diagnosis, with a SIR equal to 13.2 (95% CI = 6.90-20.9) in women above 50 years of age. Our findings for the first time support the hypothesis that ovarian endometrioma increases the subsequent risk of developing ovarian cancer in Shizuoka, Japan.

PMID 17291229  Int J Gynecol Cancer. 2007 Jan-Feb;17(1):37-43. doi: 10・・・
著者: Hiroshi Kobayashi, Yuki Yamada, Naoki Kawahara, Kenji Ogawa, Chiharu Yoshimoto
雑誌名: Oncol Rep. 2019 Mar;41(3):1729-1738. doi: 10.3892/or.2018.6946. Epub 2018 Dec 21.
Abstract/Text In the present study, we summarize the role of the shared and independent (epi)genetic background between endometrioid carcinoma (EC) and clear cell carcinoma (CCC), two histological subtypes of endometriosis-associated ovarian cancer (EAOC). Using the PubMed database, we conducted a literature review of various studies related to the malignant transformation of endometriosis. Both endometriosis and EAOC face potential environmental hazards, including hemoglobin (Hb), heme and free iron, which induces DNA damage and mutations. Although EC is distinguished from CCC due to different morphologies, both represent common environmental profiles and maintain the similar (epi)genomic abnormalities with multiple overlaps and share similar molecular signatures. By contrast, EAOC also has disease-specific gene signatures corresponding with each histological subtype: Estrogen receptor promotes EC cell proliferation ('go') and hepatocyte nuclear factor-1β (HNF-1β) induces CCC cell cycle arrest ('stop') under oxidative stress conditions. This model underscores a subtype-dependent 'go or stop' dichotomy, possibly through better ability to adapt in a changing environment. It was found that cyst fluid Hb and iron concentrations were significantly lower in EAOC when compared to benign ovarian endometrioma (OE), supporting the hypothesis that the redox imbalance plays a key role in the pathogenesis of EAOC. There are at least two phases of iron carcinogenesis and tumor progression: The initial wave of iron-induced oxidative stress and DNA mutations would be followed by the second big wave of subsequent synthesis of the antioxidants, which diminishes cellular oxidative stress capacity, increases apoptosis resistance and promotes tumor initiation and progression. Special emphasis is given to novel pathophysiological concepts of malignant transformation of endometriosis.

PMID 30592289  Oncol Rep. 2019 Mar;41(3):1729-1738. doi: 10.3892/or.20・・・
著者: G A J Dunselman, N Vermeulen, C Becker, C Calhaz-Jorge, T D'Hooghe, B De Bie, O Heikinheimo, A W Horne, L Kiesel, A Nap, A Prentice, E Saridogan, D Soriano, W Nelen, European Society of Human Reproduction and Embryology
雑誌名: Hum Reprod. 2014 Mar;29(3):400-12. doi: 10.1093/humrep/det457. Epub 2014 Jan 15.
Abstract/Text STUDY QUESTION: What is the optimal management of women with endometriosis based on the best available evidence in the literature?
SUMMARY ANSWER: Using the structured methodology of the Manual for ESHRE Guideline Development, 83 recommendations were formulated that answered the 22 key questions on optimal management of women with endometriosis.
WHAT IS KNOWN ALREADY: The European Society of Human Reproduction and Embryology (ESHRE) guideline for the diagnosis and treatment of endometriosis (2005) has been a reference point for best clinical care in endometriosis for years, but this guideline was in need of updating.
STUDY DESIGN, SIZE, DURATION: This guideline was produced by a group of experts in the field using the methodology of the Manual for ESHRE Guideline Development, including a thorough systematic search of the literature, quality assessment of the included papers up to January 2012 and consensus within the guideline group on all recommendations. To ensure input from women with endometriosis, a patient representative was part of the guideline development group. In addition, patient and additional clinical input was collected during the scoping and review phase of the guideline.
PARTICIPANTS/MATERIALS, SETTING, METHODS: NA.
MAIN RESULTS AND THE ROLE OF CHANCE: The guideline provides 83 recommendations on diagnosis of endometriosis and on the treatment of endometriosis-associated pain and infertility, on the management of women in whom the disease is found incidentally (without pain or infertility), on prevention of recurrence of disease and/or painful symptoms, on treatment of menopausal symptoms in patients with a history of endometriosis and on the possible association of endometriosis and malignancy.
LIMITATIONS, REASONS FOR CAUTION: We identified several areas in care of women with endometriosis for which robust evidence is lacking. These areas were addressed by formulating good practice points (GPP), based on the expert opinion of the guideline group members.
WIDER IMPLICATIONS OF THE FINDINGS: Since 32 out of the 83 recommendations for the management of women with endometriosis could not be based on high level evidence and therefore were GPP, the guideline group formulated research recommendations to guide future research with the aim of increasing the body of evidence.
STUDY FUNDING/COMPETING INTEREST(S): The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the implementation of the guideline. The guideline group members did not receive payment. All guideline group members disclosed any relevant conflicts of interest (see Conflicts of interest).
TRIAL REGISTRATION NUMBER: NA.

PMID 24435778  Hum Reprod. 2014 Mar;29(3):400-12. doi: 10.1093/humrep/・・・
著者: D L Olive, E A Pritts
雑誌名: N Engl J Med. 2001 Jul 26;345(4):266-75. doi: 10.1056/NEJM200107263450407.
Abstract/Text
PMID 11474666  N Engl J Med. 2001 Jul 26;345(4):266-75. doi: 10.1056/N・・・
著者: Tasuku Harada, Mikio Momoeda, Yuji Taketani, Hiroshi Hoshiai, Naoki Terakawa
雑誌名: Fertil Steril. 2008 Nov;90(5):1583-8. doi: 10.1016/j.fertnstert.2007.08.051. Epub 2007 Dec 27.
Abstract/Text OBJECTIVE: To evaluate the efficacy of a low-dose oral contraceptive pill (OCP) for patients with dysmenorrhea associated with endometriosis.
DESIGN: A double-blind, randomized, placebo-controlled trial.
SETTINGS: Clinical trial sites in Japan.
PATIENT(S): One hundred patients with dysmenorrhea associated with endometriosis. Most enrolled patients had radiologic evidence of endometriosis rather than surgical diagnosis.
INTERVENTION(S): Patients were randomly assigned to receive either monophasic OCP (ethinylestradiol plus norethisterone) or placebo. Participants used their usual pain medications as needed during the trial.
MAIN OUTCOME MEASURE(S): After four cyclic treatments, we used a zero- to three-point verbal rating scale and a visual analogue scale to measure the severity of disability because of dysmenorrhea in daily life, and the patients' use of analgesics.
RESULT(S): Total dysmenorrhea scores assessed by the verbal rating scale were significantly decreased at the end of treatment in both groups. From the first cycle through the end of treatment, dysmenorrhea in the OCP group was significantly milder than in the placebo group. Nonmenstrual pelvic pain was present at baseline in 24.5% (12 of 49) of the OCP group and 34.0% (16 of 47) of the placebo group. The volume of endometrioma (larger than 3 cm in diameter) was significantly decreased in the OCP group, but not in the placebo group. No serious adverse events related to using OCPs occurred.
CONCLUSION(S): The present study clearly demonstrated for the first time that OCPs could be used to effectively and safely treat pain associated with endometriosis.

PMID 18164001  Fertil Steril. 2008 Nov;90(5):1583-8. doi: 10.1016/j.fe・・・
著者: Tasuku Harada, Mikio Momoeda, Yuji Taketani, Takeshi Aso, Masao Fukunaga, Hiroshi Hagino, Naoki Terakawa
雑誌名: Fertil Steril. 2009 Mar;91(3):675-81. doi: 10.1016/j.fertnstert.2007.12.080. Epub 2008 Jul 23.
Abstract/Text OBJECTIVE: To compare the efficacy and safety of dienogest (DNG) with intranasal buserelin acetate (BA) in patients with endometriosis.
DESIGN: Phase III, randomized, double-blind, multicenter, controlled trial.
SETTING: Twenty-four study centers in Japan.
PATIENT(S): Two hundred seventy-one patients with endometriosis.
INTERVENTION(S): Dienogest (2 mg/day, orally) or BA (900 microg/day, intranasally) for 24 weeks.
MAIN OUTCOME MEASURE(S): The pre- to posttreatment changes in the scores of five subjective symptoms during nonmenstruation (lower abdominal pain, lumbago, defecation pain, dyspareunia, and pain on internal examination) and two objective findings (induration in the pouch of Douglas and limited uterine mobility).
RESULT(S): Dienogest reduced the scores of all symptoms and findings at the end of treatment, and the mean changes in the scores of all symptoms and findings except induration in the pouch of Douglas were comparable to those obtained with BA. Compared with BA, DNG was associated with irregular genital bleeding more frequently and with fewer hot flushes. The reduction in bone mineral density (BMD) during DNG treatment was significantly lower than that during BA treatment.
CONCLUSION(S): DNG is as effective as intranasal BA in alleviating endometriosis, and causes less BMD loss.

PMID 18653184  Fertil Steril. 2009 Mar;91(3):675-81. doi: 10.1016/j.fe・・・
著者: T Strowitzki, J Marr, C Gerlinger, T Faustmann, C Seitz
雑誌名: Hum Reprod. 2010 Mar;25(3):633-41. doi: 10.1093/humrep/dep469. Epub 2010 Jan 19.
Abstract/Text BACKGROUND: Dienogest is a selective progestin that has been investigated in a clinical trial programme for the treatment of endometriosis. The current non-inferiority trial compared the efficacy and safety of dienogest against leuprolide acetate (LA) for treating the pain associated with endometriosis.
METHODS: Patients with confirmed endometriosis were randomized to treatment with dienogest (2 mg/day, orally) or LA (3.75 mg, depot i.m. injection, every 4 weeks) for 24 weeks. The primary efficacy variable was absolute change in pelvic pain from baseline to end of treatment, assessed by visual analogue scale (VAS). Safety variables included adverse event profile, laboratory parameters, bone mineral density (BMD), bone markers and bleeding patterns.
RESULTS: A total of 252 women were randomized to treatment with dienogest (n = 124) or LA (n = 128); 87.9 and 93.8% of the respective groups completed the trial. Absolute reductions in VAS score from baseline to Week 24 were 47.5 mm with dienogest and 46.0 mm with LA, demonstrating the equivalence of dienogest relative to LA. Hypoestrogenic effects (e.g. hot flushes) were reported less frequently in the dienogest group. As expected, bleeding episodes were suppressed less with dienogest than with LA. Changes in mean lumbar BMD between screening and final visit were +0.25% with dienogest and -4.04% with LA subgroups (P = 0.0003). Markers of bone resorption increased with LA but not dienogest.
CONCLUSIONS: Dienogest 2 mg/day orally demonstrated equivalent efficacy to depot LA at standard dose in relieving the pain associated with endometriosis, although offering advantages in safety and tolerability.

PMID 20089522  Hum Reprod. 2010 Mar;25(3):633-41. doi: 10.1093/humrep/・・・
著者: J D Miller, R W Shaw, R F Casper, J A Rock, E J Thomas, W P Dmowski, E Surrey, L R Malinak, K Moghissi
雑誌名: Fertil Steril. 1998 Aug;70(2):293-6.
Abstract/Text OBJECTIVE: To determine the duration of time to the recurrence of pain attributable to endometriosis after the discontinuation of treatment with danazol or a GnRH agonist (GnRH-a) in patients who have had a satisfactory response to the treatment.
DESIGN: Retrospective study.
SETTING: Nine academic medical centers in three countries.
PATIENT(S): Three hundred twenty-seven women with diagnosed and staged endometriosis who were treated with at least 6 months of danazol or a GnRH-a and who experienced significant pain relief with therapy.
INTERVENTION(S): None.
MAIN OUTCOME MEASURE(S): Duration of pain relief after completion of treatment as determined by a patient-initiated report of pain recurrence or increase in pain severity requiring intervention.
RESULT(S): The median time to the recurrence of pain was 6.1 months for patients treated with danazol and 5.2 months for patients treated with a GnRH-a.
CONCLUSION(S): Although there was a lack of uniformity in treatment effects across sites, the analyses have taken into account major covariant effects. The time to the recurrence of endometriosis-associated pain after danazol treatment was slightly longer than that after GnRH-a treatment.

PMID 9696224  Fertil Steril. 1998 Aug;70(2):293-6.
著者: Richard S Legro, Jaimey G Pauli, Allen R Kunselman, Juliana W Meadows, James S Kesner, Richard J Zaino, Laurence M Demers, Carol L Gnatuk, William C Dodson
雑誌名: J Clin Endocrinol Metab. 2008 Feb;93(2):420-9. doi: 10.1210/jc.2007-2287. Epub 2007 Dec 4.
Abstract/Text CONTEXT: Continuous oral contraception may better suppress the ovary and endometrium, lending itself to the treatment of other medical conditions.
OBJECTIVE: Our objective was to determine the effects of continuous vs. cyclical oral contraception.
DESIGN: This was a randomized double-blind trial.
SETTING: This trial was performed at an academic medical center in Pennsylvania.
PATIENTS: A total of 62 healthy women with regular menses were included in the study.
INTERVENTION: Cyclical oral contraception (21-d active/7-d placebo given for six consecutive 28-d cycles) vs. continuous (168-d active pill) therapy using a monophasic pill (20 microg ethinyl estradiol and 1 mg norethindrone acetate) was examined.
MAIN OUTCOME MEASURES: The primary outcome was vaginal bleeding, and secondary outcomes included hormonal, pelvic ultrasound, quality of life, and safety measures.
RESULTS: There was no statistically significant difference in the number of total bleeding days between groups, but moderate/heavy bleeding was significantly greater with the cyclical regimen [mean 11.0 d (sd 8.5) vs. continuous 5.2 d (sd 6.8); P = 0.005], with both groups decreasing over time. Endogenous serum and urinary estrogens measured over six cycles were significantly lower (P = 0.02 and 0.04, respectively) in the continuous group than the cyclical group. Women in the continuous group also had a smaller ovarian volume and lead follicle size over the course of the trial by serial ultrasound examinations. The Moos Menstrual Distress Questionnaire showed that women on continuous therapy had less associated menstrual pain (P = 0.01) and favorable improvements in behavior (P = 0.04) during the premenstrual period.
CONCLUSIONS: Continuous oral contraception does not result in a reduction of bleeding days over a 168-d period of observation but provides greater suppression of the ovary and endometrium. These effects are associated with improved patient symptomatology.

PMID 18056769  J Clin Endocrinol Metab. 2008 Feb;93(2):420-9. doi: 10.・・・
著者: Mikio Momoeda, Tasuku Harada, Naoki Terakawa, Takeshi Aso, Masao Fukunaga, Hiroshi Hagino, Yuji Taketani
雑誌名: J Obstet Gynaecol Res. 2009 Dec;35(6):1069-76. doi: 10.1111/j.1447-0756.2009.01076.x.
Abstract/Text AIM: To investigate the safety and efficacy of 52 weeks of dienogest treatment in patients with endometriosis.
METHODS: One hundred and thirty-five patients with endometriosis received 2 mg of dienogest orally each day for 52 weeks. Adverse drug reactions and bone density were evaluated. Global improvement was assessed based on the changes in severity categories of five subjective symptoms during non-menstruation (lower abdominal pain, lumbago, dyschezia, dyspareunia, and pain on vaginal examination) and two objective findings (induration involving the pouch of Douglas and limited uterine mobility).
RESULTS: The most common adverse drug reactions included metrorrhagia (71.9%), headaches (18.5%), and constipation (10.4%). No clinically significant changes were noted in the incidence or severity of reactions associated with the course of the treatment period (52 weeks). Changes from the baseline bone mineral density of the lumbar spine measured by dual-energy X-ray absorptiometry were -1.6 +/- 2.4% and -1.7 +/- 2.2% (mean +/- standard deviation) at 24 and 52 weeks, respectively, which were statistically significant decreases; however, there was no cumulative decrease. The proportions of patients assessed as marked or moderate improvement in terms of global improvement were 72.5% (95/131 cases) at 24 weeks and 90.6% (106/117 cases) at 52 weeks.
CONCLUSION: The long-term effect of dienogest on bone mineral density was slight, whereas the efficacy increased cumulatively.

PMID 20025633  J Obstet Gynaecol Res. 2009 Dec;35(6):1069-76. doi: 10.・・・
著者: Errico Zupi, Daniela Marconi, Marco Sbracia, Fulvio Zullo, Bonaventura De Vivo, Caterina Exacustos, Giuseppe Sorrenti
雑誌名: Fertil Steril. 2004 Nov;82(5):1303-8. doi: 10.1016/j.fertnstert.2004.03.062.
Abstract/Text OBJECTIVE: To determine the efficacy of GnRH analogue plus add-back therapy compared with GnRH analogue alone and estroprogestin in patients with relapse of endometriosis-associated pain.
DESIGN: Randomized, controlled study.
SETTING: University hospital.
PATIENT(S): One hundred thirty-three women with relapse of endometriosis-related pain after previous endometriosis surgery.
INTERVENTION(S): Forty-six women were treated with GnRH analogue plus add-back therapy, 44 women were given GnRH analogue alone, and 43 women received estroprogestin, for 12 months.
MAIN OUTCOME MEASURE(S): Pain evaluation by a visual analogue scale, quality of life in treated patients according to the SF-36 questionnaire, and occurrence of adverse effects, including bone mass density loss, at pretreatment, after 6 months of treatment, at the end of treatment (12 months), and 6 months after discontinuation of treatment.
RESULT(S): Patients treated either with GnRH analogue alone or GnRH analogue plus add-back therapy showed a higher reduction of pelvic pain, dysmenorrhea, and dyspareunia than patients treated with oral contraceptive, whereas patients treated with add-back therapy showed a better quality of life, as assessed with the SF-36 questionnaire, and adverse effects rate than the other two groups.
CONCLUSION(S): Add-back therapy allows the treatment of women with relapse of endometriosis-associated pain for a longer period, with reduced bone mineral density loss, good control of pain symptoms, and better patient quality of life compared with GnRH analogue alone or oral contraceptive.

PMID 15533351  Fertil Steril. 2004 Nov;82(5):1303-8. doi: 10.1016/j.fe・・・
著者: Jo Kitawaki, Hiroaki Ishihara, Miyo Kiyomizu, Hideo Honjo
雑誌名: Fertil Steril. 2008 Jun;89(6):1831-5. doi: 10.1016/j.fertnstert.2007.05.052. Epub 2007 Aug 30.
Abstract/Text Pelvic pain associated with endometriosis was treated by the long-term administration of a tapering dose of danazol or mid/low doses of oral contraceptives after the end of therapy involving a GnRH agonist (GnRH-a). Results demonstrated that each of these three therapies is a practical and efficient treatment regimen to maintain the relief of pelvic pain achieved by GnRH-a therapy, at least for a period of 12 months.

PMID 17761178  Fertil Steril. 2008 Jun;89(6):1831-5. doi: 10.1016/j.fe・・・
著者: Jo Kitawaki, Izumi Kusuki, Kaoruko Yamanaka, Izumi Suganuma
雑誌名: Eur J Obstet Gynecol Reprod Biol. 2011 Aug;157(2):212-6. doi: 10.1016/j.ejogrb.2011.03.012. Epub 2011 Apr 6.
Abstract/Text OBJECTIVE: To examine whether long-term administration of dienogest following gonadotropin-releasing hormone agonist (GnRH-a) therapy would prolong the relief of pelvic pain while reducing the amount of irregular uterine bleeding.
STUDY DESIGN: This was a prospective, non-randomized clinical trial. Among the patients suffering from chronic pelvic pain associated with recurrent endometriosis, Group G (n=38) received GnRH-a for 4-6 months and then dienogest (1 mg/day) for 12 months. The dose of dienogest was increased to 1.5 or 2 mg/day when a patient had uncontrollable uterine bleeding {n=15 (39%)}. Group D (n=33) received only dienogest (2 mg/day) for 12 months. Pelvic pain was assessed using a visual analog scale (VAS). Uterine bleeding was semi-quantified using a pictorial blood loss assessment chart (PBAC).
RESULTS: In Group G, GnRH-a significantly reduced the VAS score for pelvic pain, and alleviation was maintained during the 12-month therapy with dienogest. There was no significant difference in pain reduction between Group G and Group D. The PBAC score during the first 6 months on dienogest was significantly smaller in Group G than in Group D.
CONCLUSION: Treatment with a GnRH-a followed by long-term dienogest therapy maintains the relief of endometriosis-associated pelvic pain achieved with GnRH-a therapy for at least 12 months. This regimen reduces the amount of irregular uterine bleeding that often occurs during the early phase of dienogest therapy.

Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
PMID 21474232  Eur J Obstet Gynecol Reprod Biol. 2011 Aug;157(2):212-6・・・
著者: Jeremy Wright, Hany Lotfallah, Kevin Jones, David Lovell
雑誌名: Fertil Steril. 2005 Jun;83(6):1830-6. doi: 10.1016/j.fertnstert.2004.11.066.
Abstract/Text OBJECTIVE: To compare excisional and ablative treatment modalities for mild (revised American Fertility score 1-2) endometriosis in the management of chronic pelvic pain.
DESIGN: A randomized study of excision or ablation for mild endometriosis, participants and investigators alike blinded to the treatment modality at the follow-up visit.
SETTING: District general hospital with a specialist pelvic pain clinic in the United Kingdom.
PATIENT(S): Women presenting with chronic pelvic pain.
INTERVENTION(S): Participants were asked to complete a questionnaire detailing symptoms related to chronic pelvic pain and rating their pain on a ranked ordinal scale. Areas of pelvic tenderness were identified and similarly ranked. At laparoscopy they were randomly assigned to excision or ablation of any endometriotic lesions, and the questionnaire was repeated at 6 months.
MAIN OUTCOME MEASURE(S): Changes in pain score on a ranked ordinal scale after surgical treatment for mild endometriosis.
RESULT(S): Both treatment modalities produced good symptomatic relief and reduction of pelvic tenderness (67%). There was no difference in morbidity; one woman in each group became pregnant during the study period. Only two participants reported no relief or a worsening of symptoms or signs.
CONCLUSION(S): This small study showed good symptom relief at 6 months from pelvic pain for the majority of participants irrespective of the treatment modality, but two participants did not improve or got worse. A high pain score before treatment was a predictor of appreciable improvement. Further work is needed to identify women in whom surgical intervention is likely to produce a good response.

PMID 15950657  Fertil Steril. 2005 Jun;83(6):1830-6. doi: 10.1016/j.fe・・・
著者: E G Hughes
雑誌名: Hum Reprod. 1997 Sep;12(9):1865-72.
Abstract/Text A systematic review was conducted to evaluate the effectiveness of intrauterine insemination (IUI) with or without ovarian stimulation using gonadotrophin in the treatment of persistent infertility. Relevant randomized controlled trials were identified by a diverse strategy including a hand search of 43 core journals from 1966 to the present. Two approaches to meta-analysis were used to summarize data. First, using a standard Mantel-Haenszel approach, eight trials comparing FSH/IUI with FSH/timed intercourse for unexplained infertility were combined. The common odds ratio for pregnancy was 2.37 [95% confidence interval (CI), 1.43, 3.90], suggesting a significant improvement with IUI following ovulation induction in this patient group. Although the data were statistically homogeneous, clinically important heterogeneity was present. Second, across all diagnostic groups, the independent effects of treatment with follicle stimulating hormone (FSH), clomiphene citrate, IUI, as well as the diagnoses of male factor and endometriosis were assessed using stepwise logistic regression. Based on 5214 cycles reported in 22 trials, the odds ratio for pregnancy associated with FSH use was 2.35 (95% CI, 1.87, 2.94) for IUI, 2.82 (95% CI, 2.18, 3.66) for male factor, 0.48 (95% CI, 0.37, 0.61), and for endometriosis 0.45 (95% CI, 0.27, 0.76). This summary of the best available evidence may prove useful in counselling couples who are considering FSH and/or IUI therapy.

PMID 9363697  Hum Reprod. 1997 Sep;12(9):1865-72.
著者: S Marcoux, R Maheux, S Bérubé
雑誌名: N Engl J Med. 1997 Jul 24;337(4):217-22. doi: 10.1056/NEJM199707243370401.
Abstract/Text BACKGROUND: Minimal or mild endometriosis is frequently diagnosed in infertile women. It is often treated by resection or ablation of the lesions, but whether this improves fertility has not been established. We carried out a randomized, controlled trial to determine whether laparoscopic surgery enhanced fecundity in infertile women with minimal or mild endometriosis.
METHODS: We studied 341 infertile women 20 to 39 years of age with minimal or mild endometriosis. During diagnostic laparoscopy the women were randomly assigned to undergo resection or ablation of visible endometriosis or diagnostic laparoscopy only. They were followed for 36 weeks after the laparoscopy or, for those who became pregnant during that interval, for up to 20 weeks of pregnancy.
RESULTS: Among the 172 women who had resection or ablation of endometriosis, 50 became pregnant and had pregnancies that continued for 20 weeks or longer, as compared with 29 of the 169 women in the diagnostic-laparoscopy group (cumulative probabilities, 30.7 percent and 17.7 percent, respectively; P=0.006 by the log-rank test). The corresponding rates of fecundity were 4.7 and 2.4 per 100 person-months (rate ratio, 1.9; 95 percent confidence interval, 1.2 to 3.1). Fetal losses occurred in 20.6 percent of all the recognized pregnancies in the laparoscopic-surgery group and in 21.6 percent of all those in the diagnostic-laparoscopy group (P=0.91). Four minor operative complications (intestinal contusion, slight tear of the tubal serosa, difficult pneumoperitoneum, and vascular trauma) were reported (three in the surgery group and one in the control group).
CONCLUSIONS: Laparoscopic resection or ablation of minimal and mild endometriosis enhances fecundity in infertile women.

PMID 9227926  N Engl J Med. 1997 Jul 24;337(4):217-22. doi: 10.1056/N・・・
著者: Kurt Barnhart, Rebecca Dunsmoor-Su, Christos Coutifaris
雑誌名: Fertil Steril. 2002 Jun;77(6):1148-55.
Abstract/Text OBJECTIVE: To investigate the IVF outcome for patients with endometriosis.
DESIGN: Meta-analysis.
SETTING: Academic research center.
PATIENT(S): A MEDLINE search and review of the literature were performed. Patients were classified by level of endometriosis, and controls were classified according to the indication for IVF.
INTERVENTION(S): Bivariate analysis and multivariate logistic regression was used to estimate overall effect and control for confounding.
MAIN OUTCOME MEASURE(S): Pregnancy rates, fertilization rate, implantation rates, and numbers of oocytes retrieved.
RESULT(S): Twenty-two published studies were included in the overall analysis. The chance of achieving pregnancy was significantly lower for endometriosis patients (odds ratio, 0.56; 95% confidence interval, 0.44-0.70) when compared with tubal factor controls. Multivariate analysis also demonstrated a decrease in fertilization and implantation rates, and a significant decrease in the number of oocytes retrieved for endometriosis patients. Pregnancy rates for women with severe endometriosis were significantly lower than for women with mild disease (odds ratio, 0.60; 95% confidence interval, 0.42-0.87).
CONCLUSION(S): Patients with endometriosis-associated infertility undergoing IVF respond with significantly decreased levels of all markers of reproductive process, resulting in a pregnancy rate that is almost one half that of women with other indications for IVF. These data suggest that the effect of endometriosis is not exclusively on the receptivity of the endometrium but also on the development of the oocyte and embryo.

PMID 12057720  Fertil Steril. 2002 Jun;77(6):1148-55.
著者: Kevin D Jones, C J G Sutton
雑誌名: Hum Reprod. 2002 Mar;17(3):782-5.
Abstract/Text BACKGROUND: In this prospective, cohort study we present the cumulative pregnancy rate following ablative laparoscopic surgery in patients with endometriomas.
METHODS: The cyst was mobilized, fenestrated, and the capsule treated with the potassium-titanyl-phosphate (KTP) laser or bipolar diathermy. Pre- and post-operative transvaginal ultrasound scans were performed, and a detailed fertility history recorded.
RESULTS: There were 39 women (38 intention to treat as a single procedure) who had been trying to conceive for >12 months. The mean age of the patients was 33.8 years (range 20-43), and there were 42 cysts (three bilateral) with a mean diameter of 4.8 cm (range 2-25). The mean revised American Fertility Society score was 64.9 (range 22-124), and 29 (74.4%) patients had stage IV disease. Seven patients (18%) had previously had a live birth, and 17 (43.6%) had undergone assisted conception in the past. The cumulative pregnancy rate was 15/38 (39.5%). The pregnancy rate in patients with stage IV disease was 11/28 (39.3%). There were no major complications.
CONCLUSIONS: Our results indicate that laparoscopic cyst fenestration and capsule ablation is a safe and effective treatment for improving fertility.

PMID 11870136  Hum Reprod. 2002 Mar;17(3):782-5.
著者: Edgardo Somigliana, Paolo Vercellini, Paola Viganó, Guido Ragni, Pier Giorgio Crosignani
雑誌名: Hum Reprod Update. 2006 Jan-Feb;12(1):57-64. doi: 10.1093/humupd/dmi035. Epub 2005 Sep 9.
Abstract/Text The laparoscopic excision of ovarian endometriomas appears to increase the chances of spontaneous conception, but the value of this treatment in women selected for IVF-ICSI cycles is debated. Studies recruiting women with unilateral disease and comparing ovarian responsiveness in the affected and contralateral intact gonads indicate that excision of endometriomas is associated with a quantitative damage to ovarian reserve. There are no randomized trials comparing laparoscopic excision to expectant management before IVF-ICSI cycles. The idea that surgery increases IVF pregnancy rates is not supported by the available evidence. However, the chance of conception is not the only issue that has to be considered. Some potential drawbacks are associated with both therapeutical strategies. Specifically, costs and hazard of surgical complications support expectant management whereas oocyte retrieval risks, the possibility of missing occult malignancy and endometriosis progression due to ovarian stimulation would favour surgical treatment. Alternative therapeutical options include medical treatment and ultrasound-guided aspiration. Whereas prolonged GnRH agonist down-regulation may be beneficial, data on ultrasound aspiration are more controversial.

PMID 16155094  Hum Reprod Update. 2006 Jan-Feb;12(1):57-64. doi: 10.10・・・
著者: Laura Benschop, Cindy Farquhar, Nicolien van der Poel, Maas Jan Heineman
雑誌名: Cochrane Database Syst Rev. 2010 Nov 10;(11):CD008571. doi: 10.1002/14651858.CD008571.pub2. Epub 2010 Nov 10.
Abstract/Text BACKGROUND: Endometriomata are cysts of endometriosis in the ovaries. As artificial reproductive technology (ART) cycles involve oocyte pickup from the ovaries, endometriomata may interfere with the outcome of ART.
OBJECTIVES: To determine the effectiveness and safety of surgery, medical treatment, combination therapy or no treatment for improving reproductive outcomes among women with endometriomata, prior to undergoing ART cycles.
SEARCH STRATEGY: The review authors searched: Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials, CENTRAL (The Cochrane Library), EMBASE, MEDLINE, PubMed, PsycINFO, CINAHL, DARE, trial registers for ongoing and registered trials, citation indexes, conference abstracts on the ISI Web of Knowledge, Clinical Study Results, OpenSIGLE (July 2010) and handsearched Fertility and Sterility (2008 to 2010).
SELECTION CRITERIA: Randomised controlled trials of any medical, surgical or combination therapy or expectant management for endometriomata prior to ART.
DATA COLLECTION AND ANALYSIS: The trials were independently identified and assessed for risk of bias by two authors. The authors of the trials that were potentially eligible for inclusion were contacted for additional information. Outcomes were expressed as Peto odds ratios and mean differences (MD).
MAIN RESULTS: Eleven trials were identified of which seven were excluded and four with 312 participants were included.No trial reported live birth outcomes. One trial compared gonadotropin-releasing hormone (GnRH) agonist with GnRH antagonist. There was no evidence of a difference for clinical pregnancy rate (CPR), however the number of mature oocytes retrieved (NMOR) was greater with GnRH agonists (MD -1.60, 95% CI -2.44 to -0.76) and the ovarian response was increased (estradiol (E2) levels on day of human chorionic gonadotropin (hCG) injection) (MD -456.30, 95% CI -896.06 to -16.54).Surgery (aspiration or cystectomy) versus expectant management (EM) showed no evidence of a benefit for clinical pregnancy with either technique. Aspiration was associated with greater NMOR (MD 0.50, 95% CI 0.02 to 0.98) and increased ovarian response (E2 levels on day of hCG injection) (MD 685.3, 95% CI 464.50 to 906.10) compared to EM.Cystectomy was associated with a decreased ovarian response to controlled ovarian hyperstimulation (COH) (MD -510.00, 95% CI -676.62 to -343.38); no evidence of an effect on the NMOR compared to EM. Aspiration versus cystectomy showed no evidence of a difference in CPR or the NMOR.
AUTHORS' CONCLUSIONS: There was no evidence of an effect on reproductive outcomes in any of the four included trials. Further RCTs of management of endometrioma in women undergoing ART are required.

PMID 21069706  Cochrane Database Syst Rev. 2010 Nov 10;(11):CD008571. ・・・
著者: Ioanna Tsoumpou, Maria Kyrgiou, Tarek A Gelbaya, Luciano G Nardo
雑誌名: Fertil Steril. 2009 Jul;92(1):75-87. doi: 10.1016/j.fertnstert.2008.05.049. Epub 2008 Aug 9.
Abstract/Text OBJECTIVE: To investigate the effect of surgical treatment of endometrioma on pregnancy rate and ovarian response to gonadotrophin stimulation in women undergoing IVF.
DESIGN: A systematic review and meta-analysis.
SETTING: Tertiary referral center for reproductive medicine.
PATIENT(S): Subfertile women with endometrioma undergoing IVF.
INTERVENTION(S): Surgical removal of endometrioma or expectant management.
MAIN OUTCOME MEASURE(S): Clinical pregnancy rate and ovarian response to gonadotrophins (number of gonadotrophin ampoules, peak E(2) levels, number of oocytes retrieved, and number of embryos available for transfer).
RESULT(S): A search of three electronic databases for articles published between January 1985 and November 2007 yielded 20 eligible studies. Meta-analysis was conducted for five studies that compared surgery vs. no treatment of endometrioma. There was no significant difference in clinical pregnancy rate between the treated and the untreated groups. Similarly, no significant difference was found between the two groups with regard to the outcome measures used to assess the response to controlled ovarian hyperstimulation with gonadotrophins.
CONCLUSION(S): Collectively the available data in the literature show that surgical management of endometriomas has no significant effect on IVF pregnancy rates and ovarian response to stimulation compared with no treatment. Randomized controlled trials are needed before producing best-practice recommendations on this topic.

PMID 18692796  Fertil Steril. 2009 Jul;92(1):75-87. doi: 10.1016/j.fer・・・
著者: J A Collins, E A Burrows, A R Wilan
雑誌名: Fertil Steril. 1995 Jul;64(1):22-8.
Abstract/Text OBJECTIVE: To estimate the likelihood of live birth and the impact of prognostic factors among untreated infertile couples.
DESIGN: Cohort follow-up study.
SETTING: Eleven infertility clinics in academic medical centers.
PATIENTS: Two thousand one hundred ninety-eight couples with infertility of > 1 year in duration. Untreated months of observations on 873 untreated couples (18,364 months) were combined with observations before the first treatment among 1,325 treated couples (9,761 months).
INTERVENTIONS: Diagnostic tests as indicated.
MAIN OUTCOME MEASURES: Time to conception for live birth; effect of baseline characteristics estimated by means of proportional hazards analysis.
RESULTS: There were 263 live birth conceptions during 28,125 months of untreated observations. The cumulative rate of conceptions leading to live birth was 14.3% at 12 months. The relevant prognostic factors were pregnancy history, duration of infertility, female partner's age, male defect, endometriosis, and tubal disease. A prediction score based on these factors would be accurate in approximately 62% of cases.
CONCLUSIONS: The estimation of live birth among untreated infertile couples is sufficiently accurate to be useful in the clinical management of infertility and in the planning of clinical trials.

PMID 7789569  Fertil Steril. 1995 Jul;64(1):22-8.
著者: E Hughes, J Brown, J J Collins, C Farquhar, D M Fedorkow, P Vandekerckhove
雑誌名: Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000155. doi: 10.1002/14651858.CD000155.pub2. Epub 2007 Jul 18.
Abstract/Text BACKGROUND: Endometriosis is the finding of endometrial glands or stroma in sites other than the uterine cavity. Endometriosis appears to be an oestrogen dependent condition. This hormonal dependency has prompted the therapeutic use of ovulation suppression agents, in an effort to improve subsequent fertility.
OBJECTIVES: To assess the effectiveness of ovulation suppression agents, including danazol, progestins and oral contraceptives, in the treatment of endometriosis-associated subfertility in improving pregnancy outcomes including live birth.
SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Sub-fertility Group's specialised register of trials (searched October 5th, 2007) the Cochrane Register of Controlled Trials (The Cochrane Library, Issue 3, 2007), MEDLINE (1966-October 2007), EMBASE (1980 - October 2007) and reference lists of articles.
SELECTION CRITERIA: Randomised trials comparing an ovulation suppression agent with placebo or no treatment, or a suppressive agent with danazol or a GnRH with oral contraception in women with endometriosis. A total of twenty three RCTs comparing an ovulation suppression agent with placebo or no treatment, or a suppressive agent with danazol or a GnRH with oral contraception were identified.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed quality. We contacted study authors for additional information. Quality was assessed by of method of randomization,allocation concealment, blinding, completeness of follow-up, presence or absence of crossover and co-intervention. 2 x 2 tables were generated for all relevant outcomes. Odds ratios were generated using the Peto modified Mantel-Haenszel technique. Statistical heterogeneity was assessed using the I(2) test of heterogeneity. Subgroup analysis was conducted on those couples clearly identifiable as infertile or wanting to conceive.
MAIN RESULTS: Twenty four trials were included. The odds ratio for pregnancy following ovulation suppression versus placebo or no treatment for all women randomised was 0.79 (95% CI 0.54 to 1.14), P = 0.21 and 0.80 (95% CI 0.51 to 1.24), P = 0.32 respectively for subfertile couples only despite the use of a variety of suppression agents. There was no evidence of benefit from the treatment. The common odds ratio for pregnancy following all agents versus danazol for all women randomised was 1.38 (95% CI 1.05 to 1.82), P = 0.02 and OR 1.37 (95% CI 0.94 to 1.99), P = 0.10 for subfertile couples only. When GnRHa and danazol were directly compared, OR was 1.45 (95% CI 1.08 to 1.95) P = 0.01 for all women randomised and OR 1.63( 95% CI 1.12 to 2.37), P = 0.01 for subfertile couples only in favour of GnRH. No effect was observed for GnRH compared with oral contraception; OR 0.99 (95% CI 0.52 to 1.89), P = 0.98 for all women randomised and OR 0.79 ( 95% CI 0.37 to 1.69), P = 0.55. In all analyses the data were statistically homogeneous (I(2)=0%).
AUTHORS' CONCLUSIONS: There is no evidence of benefit in the use of ovulation suppression in subfertile women with endometriosis who wish to conceive.

PMID 17636607  Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000155. d・・・
著者: R J Hart, M Hickey, P Maouris, W Buckett
雑誌名: Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004992. doi: 10.1002/14651858.CD004992.pub3. Epub 2008 Apr 16.
Abstract/Text BACKGROUND: Endometriomata are endometriotic deposits within the ovary. The surgical management of these blood filled cysts is controversial. The laparoscopic approach to the management of endometriomata is favoured over a laparotomy approach as it offers the advantage of a shorter hospital stay, faster patient recovery and decreased hospital costs. Currently the commonest procedures for the treatment of ovarian endometriomata are either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall.
OBJECTIVES: The objective of this review was to determine the most effective technique of treating an ovarian endometrioma; either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall. The end-points assessed were the relief of pain, recurrence of the endometrioma, recurrence of symptoms and in women desiring to conceive the subsequent pregnancy rate, either spontaneous or as part of fertility treatment.
SEARCH STRATEGY: The reviewers searched the Cochrane Menstrual Disorders and Subfertility Group specialised register of trials (searched 3rd March 2007), the Cochrane Register of Controlled Trials (The Cochrane Library, Issue 3, 2007), MEDLINE (1966-August 2007), EMBASE (1980- March 2007) and reference lists of articles, the handsearching of relevant journals and conference proceedings and by contacting leaders in the field of endoscopic surgery throughout the world. The Cochrane Menstrual Disorders and Subfertility Group Trials Register is based on regular searches of MEDLINE, EMBASE, CINHAL and CENTRAL.
SELECTION CRITERIA: Randomised controlled trials of excision of the cyst capsule versus drainage and electrocoagulation of the cyst in the management of ovarian endometriomata.
DATA COLLECTION AND ANALYSIS: Reviewers assessed eligibility and trial quality.
MAIN RESULTS: No randomised studies of the management of endometriomata by laparotomy were found. Two randomised studies of the laparoscopic management of ovarian endometriomata of greater than 3cm in size, for the primary symptom of pain were included. Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced recurrence rate of the symptoms of dysmenorrhea (OR 0.15 CI 0.06-0.38), dyspareunia (OR 0.08 CI 0.01-0.51) and non-menstrual pelvic pain (OR 0.10 CI 0.02-0.56), a reduced rate of recurrence of the endometrioma (OR 0.41 CI 0.18-0.93) and with a reduced requirement for further surgery (OR 0.21 CI 0.05-0.79) than surgery to ablate the endometrioma. For those women subsequently attempting to conceive it was also associated with a subsequent increased spontaneous pregnancy rate in women who had documented prior sub-fertility (OR 5.21 CI 2.04-13.29). A further randomised study was identified that demonstrated an increased ovarian follicular response to gonadotrophin stimulation for women who had undergone excsional surgery when compared to ablative surgery (WMD 0.6 CI 0.04-1.16). There is insufficient evidence to favour excisional surgery over ablative surgery with respect to the chance of pregnancy after controlled ovarian stimulation and intra-uterine insemination (OR 1.40 CI 0.47-4.15) .
AUTHORS' CONCLUSIONS: There is good evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and in women who were previously subfertile, subsequent spontaneous pregnancy . Consequently this approach should be the favoured surgical approach. However in women who may subsequently may undergo fertility treatment insufficient evidence exists to determine the favoured surgical approach.

PMID 18425908  Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004992. d・・・
著者: Mauro Busacca, Jennifer Riparini, Edgardo Somigliana, Giulia Oggioni, Stefano Izzo, Michele Vignali, Massimo Candiani
雑誌名: Am J Obstet Gynecol. 2006 Aug;195(2):421-5. doi: 10.1016/j.ajog.2006.03.064. Epub 2006 May 8.
Abstract/Text OBJECTIVE: This study was undertaken to determine the frequency of postsurgical ovarian failure in patients undergoing laparoscopic excision of bilateral endometriomas.
STUDY DESIGN: Patients who had been operated on for bilateral ovarian endometriosis between January 1995 and December 2003 and who were younger than 40 years at the time of surgery were contacted by telephone and interviewed.
RESULTS: A total of 126 patients were recruited. Mean +/- SD age of patients at the time of surgery was 30.4 +/- 4.3 years. Postsurgical ovarian failure was documented in 3 cases, corresponding to a rate of 2.4% (95% CI 0.5%-6.8%). In all cases, this complication occurred immediately after surgery.
CONCLUSION: Patients who had been operated on for bilateral endometriomas have a low but definite risk of premature ovarian failure occurring immediately after surgery.

PMID 16681984  Am J Obstet Gynecol. 2006 Aug;195(2):421-5. doi: 10.101・・・
著者: Hye Jin Chang, Sang Hoon Han, Jung Ryeol Lee, Byung Chul Jee, Byoung Ick Lee, Chang Suk Suh, Seok Hyun Kim
雑誌名: Fertil Steril. 2010 Jun;94(1):343-9. doi: 10.1016/j.fertnstert.2009.02.022. Epub 2009 Apr 5.
Abstract/Text OBJECTIVE: To evaluate the ovarian reserve changes after laparoscopic cystectomy, we prospectively evaluated pre- and postoperative serum anti-Müllerian hormone (AMH) level, and ovarian volumes.
DESIGN: Prospective longitudinal study.
SETTING: University Hospital.
PATIENT(S): Twenty women with benign ovarian masses participated; endometrioma [13], mature teratoma [6], and mucinous cystadenoma [1]. Seven patients had bilateral ovarian masses.
INTERVENTION(S): All patients had undergone laparoscopic ovarian cystectomy. Serum AMH levels were serially measured: preoperative, 1 week, 1 month, and 3 months after operation. Volumes of total ovary and ovarian mass were measured by 3D ultrasonography before operation.
MAIN OUTCOME MEASURE(S): Postoperative serum AMH level and ovarian volume.
RESULT(S): Median AMH level was 2.23 ng/mL (95% confidence interval [CI] 1.35-3.41 ng/mL) before operation, but reduced to 0.67 ng/mL (95% CI 0.44-1.70 ng/mL) at the first week postoperatively and then increased to 1.14 ng/mL (95% CI 0.79-2.36 ng/mL) in the first month and 1.50 ng/mL (95% CI 0.58-3.26 ng/mL) in the third month. The serum AMH level after 3 months postoperatively was recovered to about 65% of the preoperative level. The serum AMH level at postoperative 1 week was more decreased in endometrioma compared with nonendometrioma (33.9% vs. 69.2% of preoperative level), and in bilateral group compared with unilateral group (16.9% vs. 62.9%).
CONCLUSION(S): This study suggests that ovarian reserve could be reduced after laparoscopic cystectomy; however, it could be restored thereafter up to 3 months postoperative in reproductive women.

Copyright (c) 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.
PMID 19345350  Fertil Steril. 2010 Jun;94(1):343-9. doi: 10.1016/j.fer・・・
著者: Ai Saeki, Takashi Matsumoto, Kenichiro Ikuma, Yasuhito Tanase, Fujiyuki Inaba, Hisato Oku, Atsushi Kuno
雑誌名: J Minim Invasive Gynecol. 2010 Mar-Apr;17(2):176-9. doi: 10.1016/j.jmig.2009.11.004.
Abstract/Text STUDY OBJECTIVE: To estimate the efficacy of the vasopressin injection technique for laparoscopic cystectomy of ovarian endometriomas with regard to operative time and coagulation events.
DESIGN: Prospective study (Canadian Task Force Classification II-1)
SETTING: Osaka Central Hospital in Osaka, Japan
PATIENTS: Fifteen women with single lobular similarly-sized ovarian endometrioma.
INTERVENTIONS: Women who planned to undergo laparoscopic cystectomy of endometrioma were allocated randomly to 3 groups: (1) ordinary laparoscopic cystectomy without injection, (2) laparoscopic cystectomy with the injection of saline solution, and (3) laparoscopic cystectomy with the vasopressin injection technique.
MEASUREMENTS AND MAIN RESULTS: Reviewing the video, we counted the number of pinpoint bipolar coagulations on the normal ovarian cortex that were required from the beginning of stripping until hemostasis had been achieved, as well as the times required to achieve hemostasis. The group with the vasopressin injection technique required significantly fewer coagulation events (p=.041) to achieve hemostasis, as compared with the group receiving an ordinary cystectomy.
CONCLUSION: The vasopressin injection technique reduces the use of coagulation, in such a way as to suggest the possibility to protect ovarian reserves.

Copyright 2010 AAGL. Published by Elsevier Inc. All rights reserved.
PMID 20226404  J Minim Invasive Gynecol. 2010 Mar-Apr;17(2):176-9. doi・・・
著者: H N Sallam, J A Garcia-Velasco, S Dias, A Arici
雑誌名: Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004635. doi: 10.1002/14651858.CD004635.pub2. Epub 2006 Jan 25.
Abstract/Text BACKGROUND: Women with endometriosis who are treated with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) have a lower pregnancy rate compared to women with tubal factor infertility. It has been suggested that the administration of gonadotrophin releasing hormone (GnRH) agonists for a few months prior to IVF or ICSI increases the pregnancy rate.
OBJECTIVES: To determine the effectiveness of administering GnRH agonists for three to six months prior to IVF or ICSI in women with endometriosis.
SEARCH STRATEGY: We used computer searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the National Research Register (NRR) and the MDSG Specialised Register of controlled trials. We handsearched proceedings of annual meetings of the American Society for Reproductive Medicine (ASRM) and the European Society for Human Reproduction and Embryology (ESHRE). We reviewed lists of references in original research and review articles. We contacted experts in various countries to identify unpublished trials.
SELECTION CRITERIA: We included randomised controlled trials using any GnRH agonist prior to IVF or ICSI to treat women with any degree of endometriosis diagnosed by laparoscopy or laparotomy
DATA COLLECTION AND ANALYSIS: Two independent review authors abstracted data (HNS and JGV). We sent e-mails to investigators to seek additional information. We assessed the validity of each study using the methods suggested in the Cochrane Handbook. The data were checked by the third review author (SD) and any disagreement was resolved by arbitration with the fourth review author (AA). We generated 2 x 2 tables for principal outcome measures. The Peto-modified Mantel-Haenszel technique was used to calculate odds ratios (OR) and assess statistical heterogeneity between studies.
MAIN RESULTS: Three randomised controlled trials (with 165 women) were included. The live birth rate per woman was significantly higher in women receiving the GnRH agonist compared to the control group (OR 9.19, 95% CI 1.08 to 78.22). However, this was based on one trial reporting "viable pregnancy" only. The clinical pregnancy rate per woman was also significantly higher (three studies: OR 4.28, 95% CI 2.00 to 9.15). The information on miscarriage rates came from two trials with high heterogeneity and, therefore, results of the meta-analysis were doubtful. The included studies provided insufficient data to investigate the effects of administration of GnRH agonists on multiple or ectopic pregnancies, fetal abnormalities or other complications.
AUTHORS' CONCLUSIONS: The administration of GnRH agonists for a period of three to six months prior to IVF or ICSI in women with endometriosis increases the odds of clinical pregnancy by fourfold. Data regarding adverse effects of this therapy on the mother or fetus are not available at present.

PMID 16437491  Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004635. d・・・
著者: Mauro Busacca, Michele Vignali
雑誌名: J Minim Invasive Gynecol. 2009 Mar-Apr;16(2):142-8. doi: 10.1016/j.jmig.2008.12.013.
Abstract/Text Endometrioma is one of the most frequent pathologies in gynecologic surgery. Laparoscopic cyst excision is considered the best treatment in terms of lower recurrence and improved fertility. However, it was recently questioned whether the excision of the endometrioma could decrease the function of the operated ovary and if it could affect the subsequent fertility. Even if a consistent amount of ovarian tissue is unintentionally removed together with the capsule of the cyst, resulting in does not show the follicular pattern observed in working ovaries. Currently, no definitive data clarify whether the damage to the ovarian reserve, observed in patient with endometrioma, is related to the surgical procedure, to the previous presence of the cyst, or both. Electrosurgial coagulation during hemostasis could play an important role in terms of damage to ovarian stroma and vascularization. Particular attention must be paid in presence of bilateral endometriotic cysts. In fact, an increase in premature ovarian failure rate was reported when both the ovaries are involved in surgery. Incase of assisted reproductive techniques, no clear evidence indicates which is the best approach for concomitant endometriotic cyst. On the base of these considerations endometriomas Should be treated only in case of pain, infertility, and in asymptomatic patients if the cyst diameter is greater than 4 cm.

PMID 19249702  J Minim Invasive Gynecol. 2009 Mar-Apr;16(2):142-8. doi・・・
著者: Xishi Liu, Lei Yuan, Fanghua Shen, Zhilin Zhu, Hongyuan Jiang, Sun-Wei Guo
雑誌名: Obstet Gynecol. 2007 Jun;109(6):1411-20. doi: 10.1097/01.AOG.0000265215.87717.8b.
Abstract/Text OBJECTIVE: To identify risk factors for and the patterns of recurrence of endometrioma and of dysmenorrhea in women with ovarian endometrioma.
METHODS: We evaluated 710 consecutive patients operated on for ovarian endometriomas who were followed up for an average of 22.4 months. Twenty factors were examined to assess their effect on risk of recurrence of endometrioma and of dysmenorrhea using survival analysis. Hazard rate also was estimated to examine recurrence patterns.
RESULTS: For recurrence of endometrioma, the revised American Fertility Society (rAFS) score, younger age at surgery, and previous medical treatment of endometriosis were identified to be risk factors. For recurrence of dysmenorrhea, rAFS score was the only risk factor. For both recurrences, there was a constant hazard rate in the first 28-30 months after surgery, indicating that the recurrence in that period is completely random. After that period, the hazard rate increased dramatically.
CONCLUSION: The total rAFS score, but not rAFS stage, is a risk factor for recurrence of both endometrioma and dysmenorrhea, indicating that the rAFS stage has little prognostic value. The existence of a completely random recurrence period may be a universal phenomenon, with its duration and the magnitude of recurrence risk determined by patient characteristics and quality of care. The second phase of much higher recurrence risk may reflect successful reseeding, reimplantation, and regrowth of ectopic endometrium. Therefore, the identification of risk factors as well as patterns of recurrence should shed better light on possible causes for recurrence, which is now poorly understood.

PMID 17540815  Obstet Gynecol. 2007 Jun;109(6):1411-20. doi: 10.1097/0・・・
著者: Byung Chul Jee, Joong Yeup Lee, Chang Suk Suh, Seok Hyun Kim, Young Min Choi, Shin Yong Moon
雑誌名: Fertil Steril. 2009 Jan;91(1):40-5. doi: 10.1016/j.fertnstert.2007.11.027. Epub 2008 Apr 18.
Abstract/Text OBJECTIVE: To analyze the influence of postoperative GnRH agonist treatment on disease recurrence after conservative laparoscopic surgery for ovarian endometriomas according to duration of the treatment.
DESIGN: Retrospective cohort study.
SETTING: University hospital.
PATIENT(S): One hundred nine consecutive premenopausal women who underwent conservative laparoscopic surgery for ovarian endometriomas (endometriosis stage III/IV) were enrolled in the study. The patients were divided into four treatment groups: expectant management (n = 37) and GnRH agonist therapy for 3 (n = 28), 4 (n = 21), and 6 months (n = 23).
INTERVENTION(S): None.
MAIN OUTCOME MEASURE(S): An ultrasound confirmed recurrence of ovarian endometriomas.
RESULT(S): The overall crude recurrence rate was 16.5% after follow-up for an average of 20.1 months. The crude recurrence and the cumulative probabilities of disease recurrence at 24/36 months tended to be lower in patients who received a GnRH agonist for 6 months (4.3%, 5.3%/5.3%) compared with those who received it for 3 months (17.9%, 12.5%/25.0%) and 4 months (28.6%, 18.9%/39.2%) and patients with expectant management (16.2%, 22.4%/37.9%). However, the differences did not reach statistical significance.
CONCLUSION(S): Treatment with GnRH agonist for six months had a beneficial impact on the recurrence rate after conservative laparoscopic surgery for ovarian endometriomas.

PMID 18377899  Fertil Steril. 2009 Jan;91(1):40-5. doi: 10.1016/j.fert・・・
著者: Renato Seracchioli, Mohamed Mabrouk, Clarissa Frascà, Linda Manuzzi, Giulia Montanari, Arianna Keramyda, Stefano Venturoli
雑誌名: Fertil Steril. 2010 Jan;93(1):52-6. doi: 10.1016/j.fertnstert.2008.09.052. Epub 2008 Oct 29.
Abstract/Text OBJECTIVE: To evaluate long-term cyclic and continuous administration of oral contraceptive pills (OCP) in preventing ovarian endometrioma recurrence after laparoscopic cystectomy.
DESIGN: Prospective, randomized, controlled trial.
SETTING: Tertiary care University Hospital.
PATIENT(S): Two hundred thirty-nine women who underwent laparoscopic excision of ovarian endometriomas.
INTERVENTION(S): Patients were divided randomly into three groups: nonusers receiving no therapy and cyclic and continuous users receiving low-dose, monophasic OCP for 24 months in cyclic or continuous administration, respectively.
MAIN OUTCOME MEASURE(S): Endometrioma recurrence, size of recurrent endometrioma, and growth rate during at least 2 years follow-up evaluated by transvaginal ultrasonography.
RESULT(S): The crude recurrence rate within 24 months was significantly lower in cyclic (14.7%) and continuous users (8.2%) compared with nonusers (29%). The recurrence-free survival was significantly lower in nonusers compared with cyclic and continuous users. The mean recurrent endometrioma diameter at first observation was significantly lower in cyclic (2.17 +/- 0.45 cm) and continuous users (1.71 +/- 0.19 cm) compared with nonusers (2.73 +/- 0.56 cm). The mean diameter increase every 6 months of follow-up was significantly reduced in cyclic users (0.31 +/- 0.18 cm) and continuous users (0.25 +/- 0.09 cm) versus nonusers (0.48 +/- 0.3 cm). No significant differences between cyclic users and continuous users in terms of endometrioma recurrence were demonstrated.
CONCLUSION(S): Long-term cyclic and continuous postoperative use of OCP can effectively reduce and delay endometrioma recurrence.

Copyright 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.
PMID 18973896  Fertil Steril. 2010 Jan;93(1):52-6. doi: 10.1016/j.fert・・・
著者: C Yap, S Furness, C Farquhar
雑誌名: Cochrane Database Syst Rev. 2004;(3):CD003678. doi: 10.1002/14651858.CD003678.pub2.
Abstract/Text BACKGROUND: Endometriosis is a common gynaecological condition which affects approximately 10% of women of reproductive age (Askenazi 1997). There is a range of symptoms and most commonly women present with dysmenorrhoea, pelvic pain, infertility or a pelvic mass. Direct visualisation and biopsy during laparoscopy or laparotomy is the gold standard diagnostic test for this condition and enables the gynaecologist to identify the location, extent and severity of the disease. Surgical therapy can be performed concurrently with diagnostic surgery and may include removal (excision) or destruction (ablation) of endometriotic tissue, division of adhesions and removal of endometriotic cysts. Laparoscopic excision or ablation of endometriosis has been shown to be effective in the management of pain in mild-moderate endometriosis. Adjunctive medical treatment pre or post-operatively may prolong the symptom-free interval.
OBJECTIVES: To determine the effectiveness of systemic medical therapies used for hormonal suppression before or after surgery for endometriosis, or before and after surgery for endometriosis in the eradication of endometriosis, improvement of symptoms, pregnancy rates and overall tolerability by comparing them with no treatment or placebo.
SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility group trials register (searched 10 September 2003), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3 2003), MEDLINE (January 1966 to September 2003), EMBASE (January 1985 to September 2003) and reference lists of articles. We also contacted researchers in the field.
SELECTION CRITERIA: Trials were included if they were randomised controlled trials of the use of systemic medical therapies for hormonal suppression before or after, or before and after surgery for endometriosis.
DATA COLLECTION AND ANALYSIS: Data extraction and quality assessment was performed independently by using relative risk or weighted mean difference and 95% confidence intervals.
MAIN RESULTS: Eleven trials were included in the review. One study comparing pre-surgical medical therapy with surgery alone showed a significant improvement in AFS scores in the medical therapy group (WMD -9.60, 95% CI -11.42 to -7.78) but this may or may not be associated with better outcomes for the patients. Post surgical hormonal suppression of endometriosis compared to surgery alone (either no medical therapy or placebo) showed no benefit for the outcomes of pain or pregnancy rates but a significant improvement in disease recurrence (AFS scores (WMD -2.30, 95% CI -4.02 to -0.58)). There were no trials identified in the search that compared hormonal suppression of endometriosis before and after surgery with surgery alone. There is no significant difference between pre surgery hormonal suppression and post surgery hormonal suppression for the outcome of pain in the one trial identified (RR 1.01, 95% CI 0.49 to 2.07). Information concerning AFS scores and ease of surgery was reported only as a descriptive summary so any difference between the groups can not be quantified from the information in the report of this trial.
REVIEWERS' CONCLUSIONS: There is insufficient evidence from the studies identified to conclude that hormonal suppression in association with surgery for endometriosis is associated with a significant benefit with regard to any of the outcomes identified. There may be a benefit of improvement in AFS scores with the pre-surgical use of medical therapy. The possible benefit should be weighed in the context of the adverse effects and costs of these therapies.

PMID 15266496  Cochrane Database Syst Rev. 2004;(3):CD003678. doi: 10.・・・
著者: Paolo Vercellini, Edgardo Somigliana, Raffaella Daguati, Paola Vigano, Francesca Meroni, Pier Giorgio Crosignani
雑誌名: Am J Obstet Gynecol. 2008 May;198(5):504.e1-5. doi: 10.1016/j.ajog.2007.11.010. Epub 2008 Feb 1.
Abstract/Text OBJECTIVE: The purpose of this study was to compare the postoperative risk of endometrioma recurrence in women using oral contraception and in those undergoing simple observation.
STUDY DESIGN: After laparoscopic excision of ovarian endometriotiomas, a cyclic, low-dose, monophasic oral contraceptive pill (OCP) was offered to women not seeking pregnancy. One month after surgery, and every 6 months afterward, the patients underwent clinical and ultrasonographic assessment.
RESULTS: Of the 277 patients who entered the study, 102 used OCP for the entire follow-up period (always users), 129 used OCP discontinuously (ever users), and 46 declined treatment (never users). The median follow-up was 28 months. Recurrent endometriotic cysts were detected in 74 subjects (27%). The 36-month cumulative proportion of subjects free from endometrioma recurrence was 94% in the always users compared with 51% in the never users (P < .001); adjusted incidence rate ratio (IRR) = 0.10 (95% CI, 0.04-0.24).
CONCLUSION: Regular postoperative use of OCP effectively prevents endometrioma recurrence.

PMID 18241819  Am J Obstet Gynecol. 2008 May;198(5):504.e1-5. doi: 10.・・・

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから