Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
Hum Reprod. 2013 Jan;28(1):109-18. doi: 10.1093/humrep/des364. Epub 2012 Oct 28.
Is the occurrence of pelvic pain in women with ovarian endometrioma associated with coexisting peritoneal lesions (PLs)?
Pelvic pain in women with ovarian endometrioma is usually associated with coexisting PLs. An increased tissue inflammatory reaction with elevated prostaglandin (PG) production may be responsible for the generation of pain.
Severe pelvic pain in women with ovarian endometrioma is reported to be associated with deeply infiltrating endometriosis. However, information on pelvic pain in women with ovarian endometriosis with and without coexistent peritoneal superficial lesions is limited.
STUDY DESIGN, SIZE AND DURATION: Retrospective clinical study with case-controlled biological research using prospectively collected tissue samples derived from women with and without endometriosis and their retrospective evaluation.
PARTICIPANTS/MATERIALS, SETTING, METHODS: We performed a retrospective cohort study conducted in 2988 cases who had laparoscopic surgery for indications of ectopic pregnancy, tubal infertility and other benign gynecologic diseases. We analyzed the occurrence of pelvic pain in the cases with ovarian endometrioma according to the distribution of coexisting PLs and pattern of intrapelvic adhesions. Inflammatory reaction of eutopic and ectopic endometria was measured by immunoreaction to macrophage marker, CD68. The tissue expression of cyclooxygenase (COX) 2 was examined by immunohistochemistry and tissue concentrations of PG F2α were measured by ELISA.
Among the 2988 surgical cases, 350 (11.7%) were found to have ovarian endometrioma at laparoscopy. Coexisting PLs were present in 269 of these women and in this group 85.4% of cases experienced pelvic pain and 14.6% had no pain. In contrast, among the 81 women with ovarian endometrioma only, 38.3% cases experienced pelvic pain and 61.7% cases had no pain and the difference between the groups was statistically significant (P < 0.01). The infiltration of CD68-immunoreactive macrophages was significantly higher in the eutopic and ectopic endometria of women with peritoneal endometriosis than in ovarian endometrioma. The tissue expression of COX2 and levels of PGF2α were significantly higher in both the eutopic and ectopic endometria derived from women with peritoneal endometriosis than in similar tissues derived from women with ovarian endometrioma.
LIMITATIONS, REASONS FOR CAUTIONS: Lack of evaluation in the detection of general or disseminated deeply infiltrating endometriosis in the pelvic cavity could be a bias or limitation in this study. Further multicenter prospective studies are needed to strengthen our current findings.
Our findings may provide some new insights to understand the physiopathology of pelvic pain in women with ovarian cystic endometriosis and may hint at proper surgical manipulation to prevent the recurrence of pelvic pain in these women.
STUDY FUNDING/COMPETING INTEREST(S): This work was supported by Grants-in-Aid for Scientific Research from the Ministry of Education, Sports, Culture, Science and Technology of Japan. There is no conflict of interest related to this study.
Not applicable.
患有卵巢子宫内膜异位症的女性出现盆腔痛是否与并存的腹膜病变（PLs）有关？
患有卵巢子宫内膜异位症的女性的盆腔痛通常与并存的 PLs 有关。组织炎症反应增强，前列腺素（PG）生成增加，可能导致疼痛产生。
据报道，患有卵巢子宫内膜异位症的女性严重盆腔痛与深部浸润性子宫内膜异位症有关。然而，关于卵巢子宫内膜异位症伴或不伴腹膜浅表病变的女性盆腔痛的信息有限。
研究设计、大小和持续时间：这是一项使用前瞻性收集的组织样本进行的回顾性临床研究，涉及有和没有子宫内膜异位症的女性，并对其进行回顾性评估，采用病例对照生物研究。
参与者/材料、设置、方法：我们进行了一项回顾性队列研究，纳入了 2988 例因异位妊娠、输卵管不孕和其他良性妇科疾病而行腹腔镜手术的患者。我们根据并存 PLs 的分布和盆腔内粘连的模式，分析了卵巢子宫内膜异位症患者发生盆腔痛的情况。通过对巨噬细胞标志物 CD68 的免疫反应来测量在位和异位子宫内膜的炎症反应。通过免疫组织化学检查环氧化酶（COX）2 的组织表达，并通过 ELISA 测量 PG F2α 的组织浓度。
在 2988 例手术病例中，腹腔镜检查发现 350 例（11.7%）患有卵巢子宫内膜异位症。在这些女性中，269 例存在并存的 PLs，其中 85.4%的病例出现盆腔痛，14.6%的病例无疼痛。相比之下，在 81 例仅患有卵巢子宫内膜异位症的女性中，38.3%的病例出现盆腔痛，61.7%的病例无疼痛，两组之间的差异具有统计学意义（P<0.01）。腹膜子宫内膜异位症患者的在位和异位子宫内膜中 CD68 免疫反应性巨噬细胞的浸润明显更高。腹膜子宫内膜异位症患者的在位和异位子宫内膜中 COX2 的组织表达和 PGF2α 水平明显高于卵巢子宫内膜异位症患者。
局限性、谨慎的原因：本研究可能存在缺陷或局限性，因为缺乏对盆腔内一般或弥散性深部浸润性子宫内膜异位症的检测。需要进一步的多中心前瞻性研究来加强我们目前的发现。
我们的研究结果可能为理解患有卵巢囊性子宫内膜异位症的女性盆腔痛的病理生理学提供一些新的见解，并提示适当的手术操作以预防这些女性盆腔痛的复发。
研究资助/利益冲突：本研究得到日本文部科学省科学研究资助的支持。与本研究无关的利益冲突。
不适用。
