The efficacy of drugs in the management of endometriosis

STUDY OBJECTIVE: To establish the crude effects of danazol and gonadotropin-releasing hormone (GnRH) analogs in the management of endometriosis. DESIGN: Prospective case-control study. SETTING: Unit of the Pathophysiology of Reproduction outpatient department. PATIENTS: Two groups of 110 women each with endometriosis (American Fertility Society score 1-3) who received danazol and GnRH analogs, and a control group who did not receive any drugs. INTERVENTIONS: Women in the treatment groups received danazol 200 mg every 8 hours for 6 months, or a different GnRH agonist at standard dosages for 6 months. Laparoscopy was performed twice, at the time of diagnosis and just before the end of treatment (or no therapy for controls). Surgical treatment of the implants was performed at the second laparoscopy. MEASUREMENTS AND MAIN RESULTS: Samples of both eutopic and ectopic endometrium were collected during both laparoscopies. Both danazol and GnRH agonists were useful in reducing the AFS scores to inactive endometriotic implants, and there were no significant differences between the effects (p <0.001). Fibrosis was found after 6 months of observation in the implants in one control woman (0.9%), in 20 patients (18.2%) treated with danazol (p <0.001 vs controls), and in 4 patients (3.6%) treated with GnRH agonists (NS vs controls). A correlation between a clinical diagnosis of AFS score zero and histologic features of fibrosis in the ectopic specimens after therapies was observed in 28% of women, with poor agreement (k = 0.07). CONCLUSIONS: Fibrosis, which represent the absence of endometrial cells within the specimens of endometriotic lesions or eutopic endometrium, did not appear in eutopic endometria but it was found in some endometriotic implants. Danazol and GnRH agonists reduced the clinical AFS scores of endometriosis, but their histologic effects in completely and permanently eliminating endometriotic implants were unacceptable.     

Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation

OBJECTIVE: To assess the efficacy of two laparoscopic methods for the management of endometriomas with regard to pain relief, pregnancy rate, and disease recurrence. DESIGN: Prospective, randomized clinical trial. SETTING: Tertiary care hospital. PATIENT(S): Sixty-four patients with advanced stages of endometriosis. INTERVENTION(S): Patients were randomly allocated at the time of laparoscopy to undergo either cystectomy of the endometrioma (group 1) or drainage of the endometrioma and bipolar coagulation of the inner lining (group 2). MAIN OUTCOME MEASURE(S): Pain relief and pregnancy rate. RESULT(S): Thirty-two patients were enrolled in each group. The 24-month cumulative recurrence rates of dysmenorrhea, deep dyspareunia, and nonmenstrual pelvic pain were lower in group 1 than in group 2 (dysmenorrhea: 15.8% versus 52.9%; deep dyspareunia: 20% versus 75%; nonmenstrual pelvic pain: 10% versus 52.9%). The median interval between the operation and the recurrence of moderate to severe pelvic pain was longer in group 1 than in group 2 (19 months [range, 13.5-24 months] versus 9.5 months [range, 3-20 months]). The 24-month cumulative pregnancy rate was higher in group 1 than in group 2 (66.7% versus 23.5%). CONCLUSION(S): For the treatment of ovarian endometriomas, a better outcome with a similar rate of complications is achieved with laparoscopic cystectomy than with drainage and coagulation.     

Endometriosis in adolescent women

With the aim of determining an effective therapy for adolescent women with endometriosis, the authors analyzed the results of laparotomy performed on 16 cases of female teenagers over a seven-year period. All patients, whose average age of menarche is 12.8, were diagnosed with endometriosis between two months and nine years after the menarche, with an average interval of 5.2 years. The chief symptoms are dysmenorrhea, pelvic pain and abdominal fullness. Of the three patients of unicornuate uterus with rudimentary horn, endometriosis was found only involving the adnexa on the side of the rudimentary horn, two of the three patients had absence of affected side kidney. Conservative operation including six cases of salpingo-oophorectomy and 10 cases of ovarian cystectomy were chosen followed by danazol treatment. One year to seven years after surgical treatment, two patients required subsequent conservative operation for recurrence of endometriosis and two other patients resumed dysmenorrhea. Two married women became pregnant 5 and 10 months after surgical and medical therapy respectively. In conclusion, adolescent endometriosis may occur around five years after menarche and an obstructive uterine anomaly, enhancing retrograde menstruation, increases the occurrence rate. The symptoms and treatment of endometriosis in teenage group do not really differ from that in the older women. In the treatment of endometriosis and for the prevention of recurrence, it is recommended to give three to six months of danazol after surgical treatment.     

The effect of regular exercise on women receiving danazol for treatment of endometriosis

OBJECTIVE: To determine the effects of regular exercise on women receiving danazol for the treatment of endometriosis. METHODS: Thirty-nine patients were randomized to a danazol-only or a danazol/exercise regimen in a prospective clinical trial carried out at tertiary care institutions. Patients in the danazol/exercise group were instructed to exercise four times per week, for 40 min per session, at an intensity of 20 metabolic units. Side effect profiles, pelvic symptoms, aerobic fitness, strength and hormone levels were compared for all subjects. The number of side effects of danazol was analyzed by the method of generalized estimating equations. RESULTS: The number of side effects reported during a 4-week period was 1.09-2.17 times greater for the danazol-only than for the danazol/exercise group. All patients had improvement of symptoms during treatment. The danazol/exercise group had significantly lower testosterone levels during treatment. The time to recurrence of endometriosis was not different between groups. CONCLUSIONS: Exercise during danazol therapy reduces the number of androgenic side effects. Relief of pain and time to recurrence are unaffected.     

Sutureless cartilage graft laryngotracheal reconstruction using fibrin sealant

BACKGROUND: To estimate the value of CA-125 for the diagnosis of endometriosis in women with dysmenorrhea, as well as its significance in monitoring therapy and follow-up. METHODS: One hundred and fifty-seven women undergoing laparoscopy for dysmenorrhea were prospectively studied for serum CA-125 concentration. For those with advanced endometriosis receiving danazol treatment after conservative surgery, CA-125 was also determined every month during medication and once every 12 months after treatment. RESULTS: The sensitivity and specificity of serum CA-125 for the diagnosis of endometriosis were 61.1% and 87.5% respectively. Elevated CA-125 (>35 U/ml) was noted in 65/75 cases (86.70%) with advanced endometriosis, but in only 15/56 patients (26.8%) with minimal and mild endometriosis. Although there were significantly higher CA-125 levels in unmarried women, and a negative correlation (r=-0.1970, p=0.0284) between CA-125 and parity, there was no statistical difference in incidence of endometriosis by the status of marriage or parity. Ten women with advanced endometriosis were found with persistent endometriosis by laparoscopy during danazol treatment, even though they tested with normal CA-125 levels (<35 U/ml) at that time. Fifteen patients had elevated CA-125 levels before and one year after therapy, and were confirmed with recurrence of endometriosis by laparoscopy. Nine women with elevated CA-125 levels before treatment, were found without recurrence of endometriosis and had normal CA-125 levels one year after therapy. CONCLUSION: For endometriosis, CA-125 is a valuable adjuvant in the follow-up of recurrence in patients with advanced endometriosis and initially elevated CA-125 levels. It is not an effective screening tool for patients with dysmenorrhea, or for monitoring therapy. There was no significant correlation between the development of endometriosis and reproductive factors.     

Correlation of fecundability and serum estradiol after danazol treatment in patients with advanced endometriosis

OBJECTIVE: To examine the relationship between pregnancy incidence and the level of serum E2 during danazol therapy. DESIGN: Danazol was given by 200 mg four times daily for 3 months. Serum E2 level was checked after completing the therapy, but before stopping medication. Patients then were advised to conceive at the appropriate time over a 6-month period. SETTING: Reproductive and Endocrine Laboratory of the Department of Obstetrics and Gynecology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan. PATIENTS: Infertile women with invasive endometriosis receiving conservative surgery and danazol treatment. INTERVENTIONS: Serum E2 is checked before medication and at the end of danazol therapy, but before stopping medication. MAIN OUTCOME MEASURES: Whether pregnancy is related to the change of serum E2 caused by danazol therapy. RESULTS: There were 24 pregnancies in 38 patients with invasive endometriosis after treatment. Pregnant patients had significantly lower serum E2 levels as compared with the nonpregnant patients. CONCLUSIONS: After conservative surgery for invasive endometriosis associated with infertility, the therapeutic period of danazol treatment could be shortened to 3 months. Because there is significant correlation of fecundability and serum E2 after danazol medication, serum E2 could be a guideline for predicting pregnancy or for prolonging or changing of treatment after danazol therapy.     

Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis

OBJECTIVE: To assess the longer term efficacy of laparoscopic laser surgery in the treatment of painful pelvic endometriosis and to observe the natural history of the disease at second-look laparoscopy in a control group. DESIGN: One-year follow-up of a prospective, randomized, double-blind controlled trial. SETTING: A referral center for the laparoscopic laser treatment of endometriosis. PATIENT(S): Sixty-three patients with pelvic pain and minimal to moderate endometriosis. INTERVENTION(S): After the 6-month follow-up visit, the randomization code was broken, and follow-up was continued to 1 year. Symptomatic patients were offered second-look laser laparoscopy. MAIN OUTCOME MEASURE(S): Continued symptom relief at 1 year after treatment and findings at second-look laparoscopy in symptomatic controls. RESULT(S): Symptom relief continued at 1 year in 90% of those who initially responded. All symptomatic controls had a second-look procedure, with 7 (29%) showing disease progression, 7 (29%) showing disease regression, and 10 (42%) having static disease. CONCLUSION(S): The benefits of laser laparoscopy for painful pelvic endometriosis are continued in the majority of patients at 1 year. Untreated painful endometriosis will progress or remain static in the majority of patients but will spontaneously improve in others.     

Active infective endocarditis in infants and childhood: ten-year review of surgical therapy

OBJECTIVE: The aim of this study was to determine whether or not continuous combined HRT used with GnRH-a for the treatment of endometriosis can prevent hypoestrogenic side effects associated with GnRH-a. METHODS: Forty premenopausal women with laparoscopically proven endometriosis entered the study. The patients were randomized into two groups. Group I (n = 19) received 3.75 mg i.m. leuprolide acetate (LA) every 4 weeks for 24 weeks. Group II (n = 21) received 3.7 mg LA combined with 1.25 mg oral conjugated equine estrogen (CEE) and 5 mg oral medroxyprogesterone acetate (MA). RESULTS: Total revised AFS score as well as total pelvic pain scores decreased significantly (P < .001) in both groups. However, a statistically significant difference of hot flushes and sweating was reported by women receiving LA + HRT as compared to those treated with LA alone (P < .001). Furthermore, the bone loss at the lumbar spine was 4.2% in group I compared to 0.9% in group II at the end of the study. CONCLUSIONS: This study suggests that 1.25 mg CEE + 5 mg MA is effective in preventing hypoestrogenic side effects caused by GnRH-a, while the treatment of endometriosis is not impaired.     

Excretion of urinary N-telopeptides reflects changes in bone turnover during ovarian suppression and indicates individually variable estradiol threshold for bone loss

OBJECTIVE: To evaluate the effectiveness of N-telopeptides and E2 in monitoring bone turnover during GnRH agonist- (GnRH-a) or danazol-induced hypoestrogenism. DESIGN: Comparative, nonrandomized prospective study. SETTING: Institute for the Study and Treatment of Endometriosis. PATIENT(S): Premenopausal women undergoing ovarian suppression with GnRH-a (n = 16) or danazol (n = 9). INTERVENTION(S): Serum and urine samples were collected and bone mineral density was measured before, during, and after treatment. MAIN OUTCOME MEASURE(S): N-telopeptide excretion, serum E2, and bone mineral density at L1 to L4 and femoral neck. RESULT(S): During treatment in the GnRH-a group, mean E2 levels were 53% below and N-telopeptides were 38% above the mean baseline. At 1 month post-treatment, L1 to L4 bone mineral density decreased by 3.85%. In the danazol group, E2, N-telopeptides and L1 to L4 bone mineral density changed nonsignificantly in the opposite direction with the mean 1.25% increase in L1 to L4 at 1 month post-treatment. In combined groups, L1 to L4 bone mineral density better correlated with other measures than femoral neck bone mineral density. N-telopeptide excretion was more predictive of L1 to L4 change, with correlation the highest between N-telopeptides at month 4 and bone mineral density at month 1 afterward, while E2 appeared more predictive of the less reliable femoral neck bone mineral density. Individual exceptions to the model of an E2 threshold for bone loss were observed. Also noted were high correlation between on-therapy levels of E2 and N-telopeptides, as well as the presence of a 1-month time lag between E2 and N-telopeptide changes. CONCLUSION(S): Bone density decreases during GnRH-a and may slightly increase during danazol treatment. However, E2 threshold for bone loss varies individually. N-telopeptides predict changes in bone mineral density at L1 to L4 better than E2.     

Use of a long-acting gonadotropin-releasing hormone agonist for treatment of steroid cell tumors of the ovary

OBJECTIVE: To report a complete serologic response in a 50-year-old women who received long-acting gonadotropin-releasing hormone agonist (GnRH-A) therapy for steroid cell tumor of the ovary, not otherwise specified. DESIGN: Case report. SETTING: University hospital-based reproductive biology unit. PATIENT(S): A 50-year-old female patient exhibited persistent elevation of T (>2.0 ng/mL) after surgery for steroid cell tumor of the ovary, not otherwise specified, stage IIA for 3 months. This elevation suggested the presence of some residual active tumor. INTERVENTION(S): All tumor evaluations, including those for tumor markers, a thorough physical examination, imaging studies, and evaluations of nuclear medicine studies were negative except for elevated serum T levels. The patient was treated with GnRH-a between the fourth month and sixth month postoperatively. MAIN OUTCOME MEASURE(S): Serum levels of T and tumor survey. RESULT(S): The serum T levels returned to normal limits after administration of the first dose of GnRH-a. Follow-up of tumor survey was negative. The patient was alive and free of disease 26 months after treatment with GnRH-a. CONCLUSION(S): GnRH-a may be an alternative choice as adjuvant therapy for managing a persistent or recurrent hormone-producing steroid cell tumor of the ovary.     

Percutaneous stereotactic differential radiofrequency thermal rhizotomy for the treatment of trigeminal neuralgia

PURPOSE: The purpose of this study was to evaluate the effectiveness of radiofrequency thermal rhizotomy (RTR) for trigeminal neuralgia, after failure of pharmacological management. PATIENTS AND METHODS: Two hundred fifteen patients underwent RTR from 1991 to 1996 and were prospectively evaluated. These patients were characterized by age, sex, side of the face, and division(s) involved. Patients were evaluated for pain relief, recurrence requiring or not requiring reoperation, and the type and rate of complications. They were followed-up by serial clinical evaluation and telephone interview. Patients were categorized into groups: 1) Successful result: excellent, good pain relief; and 2) Unsuccessful result: fair, poor, or no pain relief. The RTR group was compared with historical controls. Follow-up ranged from 9 to 68 months (mean, 32 months) and results were evaluated at early and long-term follow-up. RESULTS: At early follow-up (defined as immediately postoperatively to 6 months), pain relief of excellent or good quality (successful result) occurred in 198 of 215 patients (92%). Fair or poor or no pain relief (unsuccessful result) occurred in 17 (8%) patients. At long-term follow-up (>6 months to 68 months), recurrence of pain that required reoperation occurred in 24 patients (11%) and recurrence of pain that did not require reoperation (medically managed) occurred in 34 patients (16%). Dysesthesia developed in 18 patients (8%); seven patients (3%) had dysesthesia alone (medically managed) and 11 patients (5%) had dysesthesia with recurrence of pain (medically or surgically managed). "Anesthesia/analgesia dolorosa" developed in four patients (1.8%) and was medically managed. At long-term follow-up, 83% of patients had good to excellent pain relief (successful result). There were no mortalities, no significant morbidity, and a low rate of minor complications. CONCLUSION: With the use of this specific diagnostic approach and management algorithm, patients with trigeminal neuralgia can be successfully managed.     

Scrotal ulcer occurring in patients with acute promyelocytic leukemia during treatment with all-trans retinoic acid

STUDY OBJECTIVE: To evaluate the efficacy of conservative laparoscopic surgery in a series of patients with stage III-IV endometriosis. DESIGN: Prospective study (Canadian Task Force classification II-1). SETTING: University-affiliated hospital. PATIENTS: All 141 women who underwent conservative operative laparoscopy for stage III-IV endometriosis between January 1993 and December 1996 and were followed for a minimum of 6 months. INTERVENTIONS: Laparoscopic procedures performed with scissors, bipolar coagulation, and hydrodissection. MEASUREMENTS AND MAIN RESULTS: Clinical examination, transvaginal ultrasonography, and pain questionnaire were scheduled every 6 months postoperatively. The cumulative proportion of pregnant patients and cumulative recurrence rate were calculated by Kaplan-Meier method. Twenty-five women (44%) with infertility became pregnant. Twenty-three (51%) had stage III and two (16.7%, p <0.05) had stage IV endometriosis. The 24-month cumulative pregnancy rate was 57.5%. Thirty-one women (22%) reported pain recurrence during follow-up. Five (3.5%) recurrences were confirmed by histologic examination and eight (5.7%) were documented only by clinical and ultrasonographic findings. No recurrence occurred in the first 6 months of follow-up. CONCLUSION: Operative laparoscopy seems to be effective treatment for stage III endometriosis. A larger series with longer follow-up is necessary to clarify its role in the management of stage IV disease. (J Am Assoc Gynecol Laparosc 6(1):55-58, 1999)     

Tissue inhibitor of metalloproteinase-1 concentrations are attenuated in peritoneal fluid and sera of women with endometriosis and restored in sera by gonadotropin-releasing hormone agonist therapy

OBJECTIVE: To establish tissue inhibitor of metalloproteinase-1 (TIMP-1) concentrations in peritoneal fluid (PF) and sera of women with endometriosis and compare them to disease-free controls. DESIGN: Prospective randomized study. SETTING: Academic medical center. PATIENT(S): Women with laparoscopically documented endometriosis and disease-free women of reproductive age. INTERVENTION(S): Peritoneal fluid and sera were collected, and some women received gonadotropin-releasing hormone agonist (GnRH-a) therapy for endometriosis. MAIN OUTCOME MEASURE(S): Peritoneal fluid and sera TIMP-1 concentrations were measured with a specific RIA. RESULT(S): The TIMP-1 concentrations were significantly lower in PF and sera of women with endometriosis compared with disease-free women. The GnRH-a therapy restored serum TIMP-1 concentrations. CONCLUSION(S): Aberrant expression and localization of TIMP-1 may derange the proteolytic milieu of the peritoneal cavity and contribute to the etiology and underlying physiologic sequelae associated with endometriosis. Measurement of TIMP-1 in serum may aid in diagnosing endometriosis and assist with monitoring treatment efficacy in women with this disease.     

A molecular perspective of the genetic relationships of G-protein coupled melatonin receptor subtypes

OBJECTIVE: To compare the efficacy, tolerance and recurrence rate of endometriosis after 5-year follow-up of treatment with Gestrinone and Buserelin, respectively. STUDY DESIGN: A prospective study with randomized follow-up of 5 years duration (minimum) for each patient was done. We included 43 cases of endometriosis diagnosed by laparoscopy or laparotomy and treated them with Gestrinone (Group G, n = 25 cases) or Buserelin intranasal spray (Group B, n = 18) for 6 months. RESULTS: General data: Age, height, weight of patients and AFS score of endometriosis were without significant differences in either group. Specific data: A) Global clinical efficacy was good or excellent in 74% (16/25) of group G and in 78% (14/18) of group B without significant differences. B) Global clinical tolerance was good in 50% of the patients in group G and in 0% in group B (p < 0.001). C) Global evaluation after 5-year follow-up showed "success" only for 36% of patients in group G and in 33% in group B (no significant differences), with "failure" in 40% and 33%, respectively (no significant differences). CONCLUSIONS: 1) Gestrinone and Buserelin intranasal spray are valid treatments for the remission of endometriosis, with "success", "failure" and "clinical recurrence" rates similar after a follow-up of 5 years of initial treatment. 2) The most significant androgenic effect of Gestrinone was the presence of acne. Vascular effects were also considered as very undesirable effects according to the comments of patients. On the contrary, the effects of analogs are generally better tolerated.     

Role and long-term results of laparoscopic decortication in solitary cystic and autosomal dominant polycystic kidney disease

PURPOSE: Access to retroperitoneal structures via the laparoscope has become established for various conditions. This minimally invasive approach has distinct advantages over conventional open surgery. We document our experience with laparoscopic cyst decortication for diseases of the kidney, including simple and complex cysts, multiple cysts and autosomal dominant polycystic kidney disease. MATERIALS AND METHODS: We retrospectively reviewed the records of 17 patients who underwent a total of 20 procedures. Cases were categorized as polycystic kidney disease and nonpolycystic kidney disease. Factors analyzed were estimated blood loss, length of surgical procedure, hospital stay and complications. Followup included radiographic studies (computerized tomography and/or renal sonography) and patient subjective pain relief, as determined by clinical records and telephone interview. RESULTS: Nine and 11 procedures were done for nonpolycystic kidney disease and polycystic kidney disease, respectively. Of the 8 patients with polycystic kidney disease 3 underwent repeat procedures. Followup was 3 to 63 months (average 26). All patients with simple cysts who were treated for pain were pain-free at the latest followup. Of the 10 procedures 9 (90%) performed for pain relief in polycystic kidney disease successfully produced immediate pain relief. Pain-free status decreased with time with 7 of 8 (87.5%) pain-free after 6 months, and 5 of 7 (71.4%) at 1, 4 of 6 (66.7%) at 2 and 1 of 4 (25%) at 3 years. A repeat operation successfully relieved recurrent pain in 2 of 3 cases (66.7%). Of the 7 patients with polycystic kidney disease who underwent surgery for pain relief 5 (71%) are currently pain-free. CONCLUSIONS: Laparoscopic renal cyst decortication is an effective minimally invasive treatment for painful simple cysts. It is also effective for short to intermediate pain relief in autosomal dominant polycystic kidney disease. Long-term followup suggests that a repeat procedure may be necessary to maintain adequate control of symptoms in polycystic kidney disease.     

Control of carboplatin-induced emesis with a fixed low dose of granisetron (0.5 mg) plus dexamethasone

The indications, advantages, complications, and benefits of peripheral neurectomy in patients with trigeminal neuralgia were studied in detail in 40 patients treated between 1982 and 1991. Twenty-eight patients had previously received radiofrequency thermocoagulation: peripheral neurectomy was performed for pain recurrence. These patients had excellent or good pain relief for at least 5 years postsurgery. Of the 12 patients who had peripheral neurectomy as their only procedure, seven had an excellent result and five had a good result. Five of the patients had recurrence of pain after 2 years but responded well to a second neurectomy. Elderly patients who experienced pain in the first and second divisions of the trigeminal distributions were the best candidates. Peripheral neurectomy is an effective, safe procedure for elderly patients who suffer from trigeminal neuralgia and have a limited life span.     

Novel vaginal danazol ring therapy for pelvic endometriosis, in particular deeply infiltrating endometriosis

Danazol is routinely administered orally to inhibit ovulation and to treat pelvic endometriosis. However, recent evidence suggests that danazol can act directly on endometriotic tissue in vitro to inhibit DNA synthesis and induce apoptosis. Danazol was administered via the vagina in this study, using a vaginal ring drug delivery system containing 1500 mg of danazol. This therapy was effective for treatment of pelvic endometriosis, especially for deeply infiltrating endometriosis, resulting in a cure of dysmenorrhoea and tenderness in the cul-de-sac within 3 months, and of induration or nodularity in the cul-de-sac within 7 months. Moreover, conception was possible during insertion of the vaginal ring in 17 out of 31 infertile women with deeply infiltrating endometriosis, and in two out of eight infertile women with ovarian endometriotic cysts not adhering to the cul-de-sac and without deeply infiltrating endometriosis. Serum danazol concentrations, high during oral daily 400 mg danazol therapy, but undetectable during vaginal danazol ring therapy, explain why ovulation and conception could occur during insertion of the vaginal danazol ring, and why general side-effects, which are often observed during oral danazol therapy, were not observed during vaginal danazol ring therapy. Danazol seems to be absorbed through the vaginal mucosa and reaches the deeply infiltrating endometriosis via diffusion.     

Unexpected increase of the CA 19-9 tumour marker in patients with endometriosis

The purpose of this study was to investigate whether the ovarian function of women with endometriosis could be identified by serologic concentration of the oncofetal antigen CA 19-9 before, during and after treatment for 6 months with danazol. A total of 15 women with endometriosis, 20-40 years old, were studied. The serum CA 19-9 antigen was measured by immunoradiometric assay. The measurement of CA 19-9 was repeated during the last 15 days of a 6-month therapy period with danazol and after 3 months from the end of the therapy in only seven women. It was found that: 1) Eight out of 15 women (53.3%) showed higher CA 19-9 values than the upper normal limit. 2) Danazol caused a significant decrease in the antigen values which remained stable after the cessation of therapy. This data suggests that endometriosis should be classified among other diseases which cause an increase in the serum levels of CA 19-9 and that ovarian function is related to antigen levels.     

Sonographic features of ovarian remnants

Ovarian remnants occur after a portion of ovarian tissue is left behind unintentionally after oophorectomy. The ovarian remnant may be functional and cystic, producing pelvic pain and, in some patients, extrinsic compression of the distal ureter. Ovarian remnants frequently are associated with adhesions from previous pelvic surgery for endometriosis or pelvic inflammatory disease. Ovarian remnants also may be included within pelvic peritoneal inclusion cysts. In this retrospective study, the sonographic features of ovarian remnants in 10 patients with surgical proof or clinical follow-up data are described. Most ovarian remnants were simple cysts (seven of 10), three had multiple septations, and six had a rim of presumably ovarian tissue with arterial and venous flow. Three patients with ovarian remnant masses that were aspirated had symptomatic relief without recurrence. In one patient, guided aspiration was unsuccessful, probably owing to the presence of organized hemorrhage within the mass. Extrinsic compression of the distal ureter was observed in one patient, who was treated with gonadotropin releasing hormone agonist (Lupron). The sonographic findings of a completely cystic or multiseptated pelvic mass with a rim of vascularized solid tissue in a postoophorectomy patient, although such cases are rare, suggest the diagnosis of an ovarian remnant. If the diagnosis can be established with a high degree of certainty, sonographically guided aspiration may be attempted in an effort to provide symptomatic relief. Otherwise, sonography is useful in serial assessment of these masses in patients receiving medical treatment.     

Danazol for systemic lupus erythematosus with refractory autoimmune thrombocytopenia or Evans' syndrome

OBJECTIVE: To determine the efficacy of danazol for refractory autoimmune thrombocytopenia or Evans' syndrome complicating systemic lupus erythematosus (SLE). METHODS: We studied 16 consecutive patients with SLE and corticosteroid refractory autoimmune thrombocytopenia; 3 patients had coexisting autoimmune hemolysis (Evans' syndrome). Five patients had undergone splenectomy. Danazol was commenced at 200 mg/day, and increased stepwise (maximum 1200 mg/day) until benefit or toxicity was observed. After remission the danazol dose was gradually reduced to 200-400 mg/day. RESULTS: All 16 patients achieved a complete remission (platelet count >100 x 10(9)/l, hematocrit >39%) 2 months after starting danazol (range 6 weeks-8 months). Remission persisted during continued danazol therapy (mean followup 18.2 months, range 2-49 months). One patient with Evans' syndrome required discontinuation of danazol because of jaundice and biopsy proven minimal hepatic necrosis: hemolysis recurred after discontinuation of danazol. CONCLUSION: Danazol is effective for the treatment of autoimmune thrombocytopenia or Evans' syndrome complicating SLE irrespective of splenectomy status. Longer followup will be needed to determine whether the remission persists after withdrawal of danazol.