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Oligo-Anovulation Is Not a Rarer Feature in Women with Documented Endometriosis

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Oligo-Anovulation Is Not a Rarer Feature in Women with Documented Endometriosis Oligo-anovulation is not a rarer feature in women with documented endometriosis Pietro Santulli, M.D., Ph.D.,a,b Chloe Tran, M.D.,a Vanessa Gayet, M.D.,a Mathilde Bourdon, M.D.,a,b Chloe Maignien, M.D.,a Louis Marcellin, M.D.,a,b Khaled Pocate-Cheriet, M.D.,b Charles Chapron, M.D.,a,b and Dominique de Ziegler, M.D.a a Department of Gynaecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hopitaux^ de Paris (AP-HP), Hopital^ Universitaire Paris Centre, Centre Hospitalier Universitaire (CHU) Cochin, Universite Paris Descartes, Sorbonne Paris Cite; and b Department of Development, Reproduction and Cancer, Institut Cochin, INSERM U1016, Universite Paris Descartes, Sorbonne Paris Cite, Paris, France Objective: To study the prevalence of oligo-anovulation in women suffering from endometriosis compared to that of women without endometriosis. Design: A single-center, cross-sectional study. Setting: University hospital-based research center. Patient (s): We included 354 women with histologically proven endometriosis and 474 women in whom endometriosis was surgically ruled out between 2004 and 2016. Intervention: None. Main Outcome Measure(s): Frequency of oligo-anovulation in women with endometriosis as compared to that prevailing in the disease-free reference group. Results: There was no difference in the rate of oligo-anovulation between women with endometriosis (15.0%) and the reference group (11.2%). Regarding the endometriosis phenotype, oligo-anovulation was reported in 12 (18.2%) superficial peritoneal endometriosis, 12 (10.6%) ovarian endometrioma, and 29 (16.6%) deep infiltrating endometriosis. Conclusion(s): Endometriosis should not be discounted in women presenting with oligo-anovulation. (Fertil SterilÒ 2018;110:941–8. Ó2018 by American Society for Reproductive Medicine.) El resumen está disponible en Español al final del artículo. Key Words: Endometriosis, oligo-anovulation, antimullerian€ hormone, deep infiltrating endometriosis Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility- and-sterility/posts/34024-24090 ndometriosis is a chronic gyneco- increased risk of endometriosis (4–6). modes of action, local effect on lesions logic disorder of unknown origin Conversely, all medical treatments of for danazol and hypoestrogenic action E affecting up to 10% of women of proven efficacy for endometriotic for GnRH-a, showed remarkably equiv- reproductive age and 40% to 50% of lesions and symptoms, including alent efficacy on endometriotic lesions infertile women (1, 2). While the danazol, gonadotropin-releasing hor- as assessed by laparoscopy (12). The sur- etiology of endometriosis is unknown, mone agonist (GnRH-a), without and prisingly similar efficacy of danazol and progression of the disease is associated with add back therapy, oral contracep- GnRH-a led us to reconsider the pre- with the process of ovulation and tive, as well as conditions such as preg- sumed mode of action of these treat- ensuing menses (3). Indeed, exposure nancy and breast feeding, share the ments. Recognizing that the local to menses, and associated retrograde common characteristic of blocking effect of danazol is associated with ab- or back-flow bleeding, is one of ovulation (7–11). Interestingly, two sent menses, merely interfering with the factors commonly associated with therapies with purportedly different ovulation may be sufficient to amelio- rate symptomatic disease. Likewise, the Received March 25, 2017; revised June 6, 2018; accepted June 7, 2018. P.S. has nothing to disclose. C.T. has nothing to disclose. V.C. has nothing to disclose. M.B. has nothing fact that the effect of GnRH-a on endo- to disclose. C.M. has nothing to disclose. L.M. has nothing to disclose. K.P.-C. has nothing to metriosis is solely mediated by its anti- disclose. C.C. has nothing to disclose. D.d.Z. has nothing to disclose. estrogenic properties is challenged Correspondence: Dominique de Ziegler, M.D., Division Reproductive Endocrine and Infertility, Depart- ment of Obstetrics and Gynecology II, Hopital Foch Suresnes, 92150, France (E-mail: ddeziegler@ by continued efficacy in the face of me.com). add-back therapy using combined Fertility and Sterility® Vol. 110, No. 5, October 2018 0015-0282/$36.00 estrogen-progestogen preparations Copyright ©2018 American Society for Reproductive Medicine, Published by Elsevier Inc. (13). The observation that continuous https://doi.org/10.1016/j.fertnstert.2018.06.012 VOL. 110 NO. 5 / OCTOBER 2018 941 ORIGINAL ARTICLE: ENDOMETRIOSIS oral contraceptive pills as well as pregnancy are as effective as collected in all non-pregnant patients <42 years of age GnRH-a suggests that the benefit of medical treatments of who were surgically explored by operative laparoscopy or endometriosis stem from blocking ovulation rather than laparotomy for benign gynecological indications at our affecting estrogen levels (14, 15). institution between January 2004 and January 2016. For these reasons, it is not unreasonable to assume that Women with cancer and/or who did not consent were oligo-anovulation, as encountered in women suffering from excluded from this study. In case of multiple surgical inter- polycystic ovary syndrome (PCOS), would lessen the likeli- ventions at our institution during the observation period, hood of endometriosis. This, we worried, could constitute a patients were included only once during. The inclusion bias when assessing ovarian reserve by antimullerian€ hor- flow chart is illustrated in Figure 1. Indications for surgery mone (AMH) measurement in endometriosis (16). Indeed, a (possibly more than one per patient) included: pelvic pain lower incidence of oligo-anovulation, cases with characteris- defined as the presence, for at least six months, of dysmen- tically high AMH levels, could lead to AMH levels being orrhea, intermenstrual pelvic pain, and/or dyspareunia of artificially decreased in endometriosis (17). To address this moderate-to-severe intensity (22); infertility defined as at issue, we undertook to determine the incidence of oligo- least 12 months of unprotected intercourse which did not anovulation in a population of women in whom endometri- result in pregnancy (23); pelvic mass (benign ovarian cysts osis had been either, surgically confirmed or, excluded and uterine myomas, etc.); and others (uterine bleeding, (18, 19). In addition, in both groups of patients we compared request for tubal ligation, and tubal diseases). the prevalence of high serum AMH levels that had been Patients were considered as presenting with endometri- measured prior to surgery, as previously reported (20). osis only when suspected lesions were histologically confirmed. Patients who were visually diagnosed with endo- metriosis but did not have histological confirmation or who MATERIAL AND METHODS had previous surgery for endometrioma were excluded from Study Design and Population the study (21, 24). Conversely, patients who had surgery for We conducted an observational, cross sectional study using endometriosis forms other than endometrioma were a prospectively constituted database described in details retained in the study. Patients with previous endometriosis elsewhere (21). Clinical and biological information were surgery were excluded from the reference group group (25). FIGURE 1 Longitudinal flow chart of the study population. Santulli. Oligo-anovulation in endometriosis. Fertil Steril 2018. 942 VOL. 110 NO. 5 / OCTOBER 2018 Fertility and Sterility® During surgery, endometriosis was staged and scored (to- tory and were measured by a commercial enzyme-linked im- tal, implant, and adhesion scores) according to the revised muno-sorbent assay kit according to the manufacturer's American Fertility Society (rAFS) classification (26).Inaddi- instructions, as previously described (20). tion, endometriotic lesions were sorted into three phenotypes based on histological findings: superficial peritoneal endome- triosis (SUP), ovarian endometrioma (OMA), or deep infiltrating Outcome Measures endometriosis (DIE) (27, 28). DIE was histologically defined by The study aimed at determining the incidence of oligo- the endometriotic involvement of the muscularis of the target anovulation in endometriosis and the reference group. In organ (bladder, bowel, ureter, etc.) (27, 28). Because different addition, the incidence of high serum AMH levels, >4.9 ng/ forms of endometriosis (SUP, OMA, and DIE) are frequently mL, was evaluated in both endometriosis and the reference associated (29), patients were phenotyped according to their group. most severe, from least-to-most severe: SUP, OMA, and DIE Within the endometriosis group, results were compared (25, 27, 28). DIE patients were further graded according the based on disease phenotype, as determined by histological severity of the DIE lesion as follows (least-to-most severe): findings of SUP, OMA, and/or DIE. The study also analyzed uterosacral ligament(s), vagina, bladder, bowel, and ureter other serum AMH cut-off levels that are commonly quoted (30). Patients’ most severe localization was retained for in literature as evidence of high AMH levels (>4.2 ng/mL, grading and used for further analysis. Only women with >4.9 ng/mL, and 5.6 ng/mL) between endometriosis- complete excision of their endometriotic lesions were affected women and the reference group. We also compared retained for analysis because women with incomplete these 3 different serum AMH cut-off values according to surgery did not have an exact histological phenotyping
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