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Ultraschall Med 2024; 45(03): 285-292
DOI: 10.1055/a-2209-5653
Original Article

Sonomorphologic Changes in Colorectal Deep Endometriosis: The Long-Term Impact of Age and Hormonal Treatment

Sonomorphologische Veränderungen bei tief-infiltrierender kolorektaler Endometriose: Der Langzeiteffekt von Alter und hormoneller Therapie
Simon Keckstein 
1   Department of Obstetrics and Gynecology, LMU University Hospital, Munich, Germany (Ringgold ID: RIN9183)
,
Juergen Dippon
2   Institute for Stochastics and Applications, University of Stuttgart, Stuttgart, Germany (Ringgold ID: RIN9149)
,
Gernot Hudelist
3   Gynaecology, Hospital St. John of God, Vienna, Austria
,
Philippe Koninckx
4   Department for Gynecology, Latifa Hospital, Dubai, United Arab Emirates (Ringgold ID: RIN525328)
,
George Condous
5   Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, University of Sydney - Sydney Medical School Nepean, Sydney, Australia (Ringgold ID: RIN216996)
,
Lennard Schroeder
1   Department of Obstetrics and Gynecology, LMU University Hospital, Munich, Germany (Ringgold ID: RIN9183)
,
Joerg Keckstein
6   (SEF), Stiftung Endometrioseforschung, Westerstede, Germany
7   Gynecological Clinic, Gynecological Clinic Drs Keckstein, Villach, Austria
8   Department of Obstetrics and Gynecology, Ulm University Hospital, Ulm, Germany (Ringgold ID: RIN27197)
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Abstract

Purpose The progression of deep endometriosis (DE) in women of reproductive age is highly variable. This study aimed to analyze the sonomorphological changes of rectal endometriosis over long periods of time and the influence of hormonal treatment.

Methods This retrospective study included premenopausal women with rectal DE treated conservatively between 2002 and 2021. The lesion length and thickness of the nodule were evaluated at regular intervals over time. We created statistical models with mixed effects to identify potential factors influencing lesion progression and regression.

Results 38 patients were monitored over a mean period of 7.2 (± 4.2) years with a mean of 3.1 (± 2.1) check-ups within the observation period. We detected a significant increase in lesion length until the end of the fourth decade of life. In addition, we found a substantial decrease in the length and thickness of the nodule depending on the length of hormonal treatment.

Conclusion In conservatively managed patients with rectal endometriosis, without hormonal therapy, lesion size can exhibit a moderate increase up to the end of the fourth decade of life, after which it appears to stabilize. This increase does not follow a linear pattern. Hormonal therapy is crucial in impeding further progression, resulting in either a cessation or a regression of lesion growth.

Zusammenfassung

Ziel Das Wachstumsverhalten tief-infiltrierender Endometriose bei Frauen im reproduktionsfähigen Alter variiert stark. Ziel dieser Studie war es, die sonomorphologischen Veränderungen einer rektalen Endometriose im zeitlichen Verlauf zu analysieren und den Einfluss einer Hormontherapie zu untersuchen.

Material und Methoden In dieser retrospektiven Studie wurden prämenopausale Frauen mit rektosigmoidaler Endometriose eingeschlossen, die zwischen 2002 und 2021 primär konservativ behandelt wurden. Hierzu wurden Länge und Dicke der Herde in regelmäßigen Abständen sonographisch gemessen. Um Faktoren zu identifizieren, welche das Wachstumsverhalten beeinflussen könnten, wurden „Mixed-effect“-Modelle zur statistischen Analyse angewandt.

Ergebnisse Achtunddreißig Patientinnen wurden über einen Zeitraum von 7,2 (± 4,2) Jahren mit einer durchschnittlichen Anzahl von 3,1 (± 2,1) Untersuchungen überwacht. Wir konnten eine signifikante Zunahme der Herdlängen bis zum Ende des vierten Lebensjahrzehnts feststellen. Abhängig von der Dauer der Hormonbehandlung zeigte sich eine signifikante Abnahme der Länge und Dicke der Herde.

Schlussfolgerung Bei konservativ behandelten Patientinnen mit rektosigmoidaler Endometriose, ohne hormonelle Therapie, kann die Größe der Läsionen bis zum Ende des vierten Lebensjahrzehnts moderat zunehmen. Danach scheint diese sich zu stabilisieren. Die hormonelle Therapie kann eine weitere Progression des Wachstums verhindern und führt bei längerer Einnahme sogar zu einer Regression der Herde.

Keywords

deep infiltrating endometriosis - transvaginal sonography - hormonal therapy - bowel endometriosis - long-term observation

Supplementary Material



Publication History

Received: 08 August 2023

Accepted after revision: 06 November 2023

Article published online:
15 December 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Netter A. et al. Progression of deep infiltrating rectosigmoid endometriotic nodules. Human Reproduction 2019; 34 (11) 2144-2152
    PubMedGoogle Scholar
  • 2 Vercellini P. et al. Endometriosis: pathogenesis and treatment. Nature Reviews Endocrinology 2014; 10 (05) 261-275
    CrossrefPubMedGoogle Scholar
  • 3 Gordts S, Koninckx P, Brosens I. Pathogenesis of deep endometriosis. Fertility and sterility 2017; 108 (06) 872-885
    CrossrefPubMedGoogle Scholar
  • 4 Koninckx PR. et al. The epidemiology of endometriosis is poorly known as the pathophysiology and diagnosis are unclear. Best Pract Res Clin Obstet Gynaecol 2021; 71: 14-26
    CrossrefPubMedGoogle Scholar
  • 5 Abrao MS. et al. Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis. Human Reproduction 2007; 22 (12) 3092-3097
    CrossrefPubMedGoogle Scholar
  • 6 Abrao MS. et al. Clinical and Sonographic Progression of Bowel Endometriosis: 3-Year Follow-up. Reproductive Sciences 2021; 28 (03) 675-682
    CrossrefPubMedGoogle Scholar
  • 7 Nezhat C. et al. Bowel endometriosis: diagnosis and management. American journal of Obstetrics and Gynecology 2018; 218 (06) 549-562
    CrossrefPubMedGoogle Scholar
  • 8 Egekvist AG. et al. Conservative treatment of rectosigmoid endometriosis: A prospective study. Acta Obstet Gynecol Scand 2019; 98 (09) 1139-1147
    CrossrefPubMedGoogle Scholar
  • 9 Fedele L. et al. Is rectovaginal endometriosis a progressive disease?. American journal of obstetrics and gynecology 2004; 191 (05) 1539-1542
    CrossrefPubMedGoogle Scholar
  • 10 Barra F. et al. Long-term administration of dienogest for the treatment of pain and intestinal symptoms in patients with rectosigmoid endometriosis. Journal of clinical medicine 2020; 9 (01) 154
    CrossrefPubMedGoogle Scholar
  • 11 Becker CM. et al. Reevaluating response and failure of medical treatment of endometriosis: a systematic review. Fertil Steril 2017; 108 (01) 125-136
    CrossrefPubMedGoogle Scholar
  • 12 Vercellini P. et al. Medical treatment of endometriosis-related pain. Best Pract Res Clin Obstet Gynaecol 2018; 51: 68-91
    CrossrefPubMedGoogle Scholar
  • 13 Hudelist G. et al. Can transvaginal sonography predict infiltration depth in patients with deep infiltrating endometriosis of the rectum?. Hum Reprod 2009; 24 (05) 1012-1017
    CrossrefPubMedGoogle Scholar
  • 14 Guerriero S. et al. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol 2016; 48 (03) 318-332
    CrossrefPubMedGoogle Scholar
  • 15 Leonardi M, Condous G. How to perform an ultrasound to diagnose endometriosis. Australasian journal of ultrasound in medicine 2018; 21 (02) 61-69
    CrossrefPubMedGoogle Scholar
  • 16 Keckstein J. et al. The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand 2021; 100 (07) 1165-1175
    CrossrefPubMedGoogle Scholar
  • 17 Perperoglou A. et al. A review of spline function procedures in R. BMC medical research methodology 2019; 19 (01) 1-16
    CrossrefPubMedGoogle Scholar
  • 18 R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. 2020 https://www.R-project.org/
    PubMedGoogle Scholar
  • 19 Liu X, Zhang Q, Guo SW. Histological and immunohistochemical characterization of the similarity and difference between ovarian endometriomas and deep infiltrating endometriosis. Reproductive Sciences 2018; 25 (03) 329-340
    CrossrefPubMedGoogle Scholar
  • 20 Chapron C. et al. Surgery for bladder endometriosis: long-term results and concomitant management of associated posterior deep lesions. Human Reproduction 2010; 25 (04) 884-889
    CrossrefPubMedGoogle Scholar
  • 21 Donnez O, Roman H. Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection?. Fertil Steril 2017; 108 (06) 931-942
    CrossrefPubMedGoogle Scholar
  • 22 Knez J. et al. Natural progression of deep pelvic endometriosis in women who opt for expectant management. Acta Obstet Gynecol Scand 2023; DOI: 10.1111/aogs.14491.
    CrossrefPubMedGoogle Scholar
  • 23 Vercellini P. et al. Advances in the medical management of bowel endometriosis. Best Practice & Research Clinical Obstetrics & Gynaecology 2021; 71: 78-99
    CrossrefPubMedGoogle Scholar
  • 24 Ferrero S. et al. Norethisterone acetate in the treatment of colorectal endometriosis: a pilot study. Human reproduction 2010; 25 (01) 94-100
    CrossrefPubMedGoogle Scholar
  • 25 Ferrero S. et al. Triptorelin improves intestinal symptoms among patients with colorectal endometriosis. International journal of gynaecology and obstetrics 2010; 108 (03) 250-251
    CrossrefPubMedGoogle Scholar
  • 26 Vigano P. et al. Time to redefine endometriosis including its pro-fibrotic nature. Human Reproduction 2018; 33 (03) 347-352
    CrossrefPubMedGoogle Scholar
  • 27 Koninckx PR. et al. The severity and frequency distribution of endometriosis subtypes at different ages: a model to understand the natural history of endometriosis based on single centre/single surgeon data. Facts, Views & Vision in ObGyn 2021; 13 (03) 209
    CrossrefPubMedGoogle Scholar
  • 28 Roman H. et al. Colorectal Endometriosis Responsible for Bowel Occlusion or Subocclusion in Women With Pregnancy Intention: Is the Policy of Primary in Vitro Fertilization Always Safe?. J Minim Invasive Gynecol 2015; 22 (06) 1059-1067
    CrossrefPubMedGoogle Scholar
  • 29 Egekvist AG. et al. Intra- and interobserver variability in nodule size of rectosigmoid endometriosis measured by two- and three-dimensional transvaginal sonography. Acta Obstetricia et Gynecologica Scandinavica 2018; 97 (06) 734-743
    CrossrefPubMedGoogle Scholar