Endometriosis

This book attempts to achieve a difficult goal: to teach statistics to the novice so as to impart a liking and understanding of statistics. The book is geared toward a medical audience, since most examples are from the medical literature. The structure of the book consists of the following elements in each chapter: a small number of statistical rules of thumb, followed by a nontechnical explanation, a demonstration of how to work through the mechanics of doing the statistical test in question, a summary, and sample problems to be solved by the reader. (The answers, with explanations, are provided in an appendix.) Although a variety of univariate statistics are included, certain topics that are important in medical research are not. For example, there is little or no discussion of multiple regression, life-table techniques, or pooling of studies. These omissions, especially of multiple regression, are unfortunate. The Primer was derived from

Primer of Biostatistics

Prolactinomas account for approximately 40% of all pituitary adenomas and are an important cause of hypogonadism and infertility. The ultimate goal of therapy for prolactinomas is restoration or achievement of eugonadism through the normalization of hyperprolactinemia and control of tumor mass. Medical therapy with dopamine agonists is highly effective in the majority of cases and represents the mainstay of therapy. Recent data indicating successful withdrawal of these agents in a subset of patients challenge the previously held concept that medical therapy is a lifelong requirement. Complicated situations, such as those encountered in resistance to dopamine agonists, pregnancy, and giant or malignant prolactinomas, may require multimodal therapy involving surgery, radiotherapy, or both. Progress in elucidating the mechanisms underlying the pathogenesis of prolactinomas may enable future development of novel molecular therapies for treatment-resistant cases. This review provides a critical analysis of the efficacy and safety of the various modes of therapy available for the treatment of patients with prolactinomas with an emphasis on challenging situations, a discussion of the data regarding withdrawal of medical therapy, and a foreshadowing of novel approaches to therapy that may become available in the future.

/pdf/advances-in-the-treatment-of-prolactinomas-5a8n14833q.pdf

Advances in the treatment of prolactinomas.

ContextConcern regarding the adverse effects of estrogen and other hormones for treating menopausal symptoms has led to demand for other options; however, the efficacy and adverse effects of nonhormonal therapies are unclear.ObjectiveTo assess the efficacy and adverse effects of nonhormonal therapies for menopausal hot flashes by reviewing published randomized controlled trials.Data SourcesMEDLINE (1966-October 2005), PsycINFO (1974-October 2005), and the Cochrane Controlled Clinical Trials Register Database (1966-October 2005) were searched for relevant trials that provided data on treatment of menopausal hot flashes using 1 or more nonhormonal therapies.Study SelectionAll English-language, published, randomized, double-blind, placebo-controlled trials of oral nonhormonal therapies for treating hot flashes in menopausal women measuring and reporting hot flash frequency or severity outcomes.Data ExtractionTrials were identified, subjected to inclusion and exclusion criteria, and reviewed. Data on participants, interventions, and outcomes were extracted and trials were rated for quality based on established criteria. A meta-analysis was conducted for therapies with sufficient trials reporting hot flash frequency outcomes.Data SynthesisFrom 4249 abstracts, 43 trials met inclusion criteria, including 10 trials of antidepressants, 10 trials of clonidine, 6 trials of other prescribed medications, and 17 trials of isoflavone extracts. The number of daily hot flashes decreased compared with placebo in meta-analyses of 7 comparisons of selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) (mean difference, −1.13; 95% confidence interval [CI], −1.70 to −0.57), 4 trials of clonidine (−0.95; 95% CI, −1.44 to −0.47), and 2 trials of gabapentin (−2.05; 95% CI, −2.80 to −1.30). Frequency was not reduced in meta-analysis of trials of red clover isoflavone extracts and results were mixed for soy isoflavone extracts. Evidence of the efficacy of other therapies is limited due to the small number of trials and their deficiencies. Trials do not compare different therapies head-to-head and relative efficacy cannot be determined.ConclusionThe SSRIs or SNRIs, clonidine, and gabapentin trials provide evidence for efficacy; however, effects are less than for estrogen, few trials have been published and most have methodological deficiencies, generalizability is limited, and adverse effects and cost may restrict use for many women. These therapies may be most useful for highly symptomatic women who cannot take estrogen but are not optimal choices for most women.

https://jamanetwork.com/journals/jama/articlepdf/202795/jrv60004.pdf

Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis

Ovarian teratomas include mature cystic teratomas (dermoid cysts), immature teratomas, and monodermal teratomas (eg, struma ovarii, carcinoid tumors, neural tumors). Most mature cystic teratomas can be diagnosed at ultrasonography (US) but may have a variety of appearances, characterized by echogenic sebaceous material and calcification. At computed tomography (CT), fat attenuation within a cyst is diagnostic. At magnetic resonance (MR) imaging, the sebaceous component is specifically identified with fat-saturation techniques. The US appearances of immature teratoma are nonspecific, although the tumors are typically heterogeneous, partially solid lesions, usually with scattered calcifications. At CT and MR imaging, immature teratomas characteristically have a large, irregular solid component containing coarse calcifications. Small foci of fat help identify these tumors. The US features of struma ovarii are also nonspecific, but a heterogeneous, predominantly solid mass may be seen. On T1- and T2-weighted images, the cystic spaces demonstrate both high and low signal intensity. Familiarity with the US, CT, and MR imaging features of ovarian teratomas can aid in differentiation and diagnosis.

/pdf/ovarian-teratomas-tumor-types-and-imaging-characteristics-378983lwlr.pdf

Ovarian Teratomas: Tumor Types and Imaging Characteristics

Laparoscopic versus abdominal myomectomy : a prospective, randomized trial to evaluate benefits in early outcome

The efficiency of transvaginal ultrasonography in the diagnosis of endometrioma

Objective
To review the diagnostic accuracy of transvaginal ultrasound (TVS) in the preoperative detection of endometriosis in the uterosacral ligaments (USL), rectovaginal septum (RVS), vagina and bladder in patients with clinical suspicion of deep infiltrating endometriosis (DIE).

Methods
An extensive search was performed in MEDLINE (PubMed) and EMBASE for studies published between January 1989 and December 2014. Studies were considered eligible if they reported on the use of TVS for the preoperative detection of endometriosis in the USL, RVS, vagina and bladder in women with clinical suspicion of DIE using the surgical data as a reference standard. Study quality was assessed using the PRISMA guidelines and QUADAS-2 tool.

Results
Of the 801 citations identified, 11 studies (n = 1583) were considered eligible and were included in the meta-analysis. For detection of endometriosis in the USL, the overall pooled sensitivity and specificity of TVS were 53% (95%CI, 35–70%) and 93% (95%CI, 83–97%), respectively. The pretest probability of USL endometriosis was 54%, which increased to 90% when suspicion of endometriosis was present after TVS examination. For detection of endometriosis in the RVS, the overall pooled sensitivity and specificity were 49% (95%CI, 36–62%) and 98% (95%CI, 95–99%), respectively. The pretest probability of RVS endometriosis was 24%, which increased to 89% when suspicion of endometriosis was present after TVS examination. For detection of vaginal endometriosis, the overall pooled sensitivity and specificity were 58% (95%CI, 40–74%) and 96% (95%CI, 87–99%), respectively. The pretest probability of vaginal endometriosis was 17%, which increased to 76% when suspicion of endometriosis was present after TVS assessment. Substantial heterogeneity was found for sensitivity and specificity for all these locations. For detection of bladder endometriosis, the overall pooled sensitivity and specificity were 62% (95%CI, 40–80%) and 100% (95%CI, 97–100%), respectively. Moderate heterogeneity was found for sensitivity and specificity for bladder endometriosis. The pretest probability of bladder endometriosis was 5%, which increased to 92% when suspicion of endometriosis was present after TVS assessment.

Conclusion
Overall diagnostic performance of TVS for detecting DIE in uterosacral ligaments, rectovaginal septum, vagina and bladder is fair with high specificity. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1002/uog.15667

Accuracy of transvaginal ultrasound for diagnosis of deep endometriosis in uterosacral ligaments, rectovaginal septum, vagina and bladder: systematic review and meta-analysis.

Objectives
To perform a systematic review of studies comparing the diagnostic accuracy of TVS and MRI in Deep Infiltrating Endometriosis (DIE) including only studies in which patients have been underwent both techniques.

Methods
An extensive search of papers comparing TVS and MRI in DIE was performed in Medline (Pubmed) and Web of Sciences from January 1989 to January 2016. Studies were considered eligible if they reported on the use of TVS and MRI in the same set of patients for the preoperative detection of endometriosis in pelvic locations in women with clinical suspicion of DIE using the surgical data as a reference standard. Quality was assessed using QUADAS-2 tool. A random-effects model was used to determine overall pooled sensitivity, specificity, positive likelihood ratio (LR+) and negative likelihood ratio (LR–) and the diagnostic odds ratio (DOR).

Results
Of the 375 citations identified, 6 studies (n=424) were considered eligible. Pooled sensitivity, specificity, LR+ and LR– of MRI in detecting DIE in the recto-sigmoid for MRI were 0.85 (95% CI, 0.78–0.90), 0.95 (95% CI, 0.83–0.99), 18.4 (95% CI, 4.7–72.4) and 0.16 (95% CI, 0.11–0.24), respectively. Pooled sensitivity, specificity, LR+ and LR– of TVS in detecting DIE in the recto-sigmoid for TVS were 0.85 (95% CI, 0.68–0.94), 0.96 (95% CI, 0.85–0.99), 20.4 (95% CI, 4.7–88.5) and 0.16 (95% CI, 0.07–0.38), respectively. DOR was 116 (95% CI, 23-585) and 127 (95% CI, 14 - 1126), respectively.

Pooled sensitivity, specificity, LR+ and LR– of MRI in detecting DIE in the rectovaginal septum for MRI were 0.66 (95% CI, 0.51–0.79), 0.97 (95% CI, 0.89–0.99), 22.5 (95% CI, 6.7–76.2) and 0.38 (95% CI, 0.23–0.52), respectively. Pooled sensitivity, specificity, LR+ and LR– of TVS in detecting DIE in the rectovaginal septum for TVS were 0.59 (95% CI, 0.26–0.86), 0.97 (95% CI, 0.94–0.99), 23.5 (95% CI, 9.1–60.5) and 0.42 (95% CI, 0.18–0.97), respectively. DOR was 65 (95% CI, 21- 204) and 56 (95% CI, 11 - 275), respectively.

Pooled sensitivity, specificity, LR+ and LR– of MRI in detecting DIE in the uterosacral ligaments for MRI were 0.70 (95% CI, 0.55–0.82), 0.93 (95% CI, 0.87–0.97), 10.4 (95% CI, 5.1–21.2) and 0.32 (95% CI, 0.20–0.51), respectively. Pooled sensitivity, specificity, LR+ and LR– of TVS in detecting DIE in the uterosacral ligaments for TVS were 0.67 (95% CI, 0.55–0.77), 0.86 (95% CI, 0.73–0.93), 4.8 (95% CI, 2.6–9.0) and 0.38 (95% CI, 0.29–0.50), respectively. DOR was 32 (95% CI, 12- 85) and 12 (95% CI, 7- 24), respectively.

Wide confidence intervals of pooled sensitivities, specificities and DOR were present for both techniques in all the considered locations. Heterogeneity was moderate or high for sensitivity and specificity for TVS and MRI in most locations assessed. According to QUADAS2, the quality of the studies was considered good for most domains of the included studies.

Conclusions
Overall diagnostic performance of TVS and MRI for detecting DIE involving recto-sigmoid, uterosacral ligaments and rectovaginal septum is similar.

Valerio Mais

Papers

Laparoscopic versus abdominal myomectomy : a prospective, randomized trial to evaluate benefits in early outcome

The efficiency of transvaginal ultrasonography in the diagnosis of endometrioma

Accuracy of transvaginal ultrasound for diagnosis of deep endometriosis in uterosacral ligaments, rectovaginal septum, vagina and bladder: systematic review and meta-analysis.

Transvaginal ultrasound vs magnetic resonance imaging for diagnosing deep infiltrating endometriosis: systematic review and meta-analysis.

Treatment of nonendometriotic benign adnexal cysts : a randomized comparison of laparoscopy and laparotomy