Deep infiltrating endometriosis: relation between severity of dysmenorrhoea and extent of disease

Human Reproduction Vol.18, No.4 pp. 760±766, 2003 DOI: 10.1093/humrep/deg152 Deep in®ltrating endometriosis: relation between severity of dysmenorrhoea and extent of disease Charles Chapron1,3, Arnaud Fauconnier1,2, Jean-Bernard Dubuisson1, Habib Barakat1, Marco Vieira1 and GeÂrard BreÂart2 1 Service de chirurgie gyneÂcologique, Clinique universitaire Baudelocque, CHU Cochin, Saint Vincent de Paul, La Roche-Guyon, 123, bd Port-Royal 75079 Paris Cedex 14 and 2Unite Inserm 149, recherches eÂpideÂmiologiques en sante peÂrinatale et sante des femmes, Paris, 123, bd Port-Royal 75014 Paris, France 3 To whom correspondence should be addressed. E-mail: BACKGROUND: Little is known about the precise nature of the relationship between dysmenorrhoea (DM) and endometriosis. Our aim was to evaluate the relationship between the severity of DM in women with posterior deep in®ltrating endometriosis (DIE) and indicators of the extent of their disease. METHODS: Various indicators of the extent of DIE were recorded during surgery in 209 women. The severity of their DM was assessed with a pain scale. The scale was retrospective for 155 women and prospective for 54. Correlations were sought with an ordinal logistic regression model with cumulative odds. RESULTS: On univariate analysis the following variables were related to the severity of DM: number of previous surgical procedures for endometriosis; revised American Fertility society classi®cation; extensiveness of adnexal adhesion; Douglas obliteration; size of the posterior DIE implant; extent of the sub-peritoneal in®ltration by the posterior DIE (rectal, vaginal or both versus sub-peritoneal only). Current infertility was associated with less severe DM. After multiple regression analysis, presence of a rectal or vaginal in®ltration by the posterior DIE and extensiveness of adnexal adhesion were the only factors that remained related to DM severity. CONCLUSIONS: The concept of `very deep in®ltrating endometriosis', de®ned as implants invading the wall of the pelvic organ, should be tested in future classi®cation systems speci®cally addressed to the prediction of endometriosis-related pain. Key words: classi®cation system/deep in®ltrating endometriosis/dysmenorrhoea Introduction The association of dysmenorrhoea (DM) with endometriosis is well recognized. Although DM is very common in the general population of women (Jamieson and Steege, 1996), it is especially frequent among those with endometriosis (Williams and Pratt, 1977; Mahmood et al., 1991; Al-Badawi et al., 1999). Furthermore, one case±control study reported a trend between the risk of endometriosis and the severity of DM (Cramer et al., 1986), which suggests that the more extensive the disease is, the greater the severity of associated DM. Systems of endometriosis classi®cation, such as the revised American Fertility Society classi®cation (R-AFS) (The American Fertility Society, 1985), have been developed to help standardize evaluation of the extent of disease (Schenken, 1998). Several studies, however, have failed to correlate its extent, as measured by the AFS score, with the severity of dysmenorrhoea (Fedele et al., 1990; Marana et al., 1991; Vercellini et al., 1996; Porpora et al., 1999). Furthermore, little is known about the precise nature of the relationship between endometriosis and DM (Vercellini, 1997). 760 Deep in®ltrating endometriosis (DIE) is a particular form of endometriosis that penetrates >5 mm under the peritoneal surface (Koninckx and Martin, 1994). These lesions are considered very active and are strongly associated with pelvic pain symptoms (Koninckx et al., 1991). DIE implants are located in speci®c locations, primarily the posterior area (Cornillie et al., 1990; Chapron et al., 2003). Posterior DIE can involve uterosacral ligaments (Chapron and Dubuisson, 1996), torus uterinus (retrocervical area of the uterus where the uterosacral ligaments join together (Kamina, 1984), the posterior vaginal wall and the anterior rectal wall (Martin and Batt, 2001; Chapron et al., 2003). DIE implants are rather poorly re¯ected in the R-AFS classi®cation (Dubuisson and Chapron, 1994; Koninckx and Martin, 1992). This may explain why studies assessing disease extent with this classi®cation have failed to observe correlations with DM severity. Since 1992, we have conducted continuous assessment by collection of data concerning women operated on in our department for DIE. In a previous retrospective study based on the ®rst 225 women, we made an attempt to correlate distinct painful symptoms to location and characteristics of DIE ã European Society of Human Reproduction and Embryology Deep in®ltrating endometriosis and dysmenorrhoea Table I. Characteristics of the 209 women in the study No Age (years) BMI (kg/m2) Gravidity Parity No. with previous surgery for endometriosis Main operative indicationa Chronic pelvic pain symptomsb Infertilityc Ovarian cyst No. of distinct DIE implants per woman AFS staged I II III IV No. with endometrioma 100 186 110 29 43 69 52 45 57 Mean 6 1 SD 30.9 6 5.3 21.0 6 2.8 0.6 6 1.0 0.3 6 0.7 1.3 6 0.6 % 47.8 89.0 52.6 13.9 20.6 33.0 24.9 21.5 27.3 aNine women had three indications; 98 had two indications; 102 had one indication. bIncluding urinary tract symptoms and gastrointestinal symptoms. c1 year without conception. dAmerican Fertility Society stage based on The American Fertility Society, 1985. DM = dysmenorrhoea; DIE = deeply in®ltrating endometriosis; BMI = body mass index; No. = number. (Fauconnier et al., 2002). Surprisingly, we failed to correlate severe DM with any of the characteristics of the DIE implants. However, in this study DM was not evaluated in a standardized way in a questionnaire. The purpose of the present study is therefore to evaluate the relationship between indicators of disease extent and intensity of DM (using a standardized measurement) in a population of women with posterior DIE. Materials and methods Population study This study includes all the women who underwent surgery for infertility, pelvic pain symptoms (including DM, deep dyspareunia and non-menstrual pain) or adnexal masses between June, 1992 and December, 2000 and were diagnosed with posterior DIE. This determination was made during the diagnostic phase of the surgery (The American Fertility Society, 1993) and was based on the macroscopic appearance of the lesion, using the following criteria: (i) palpable and visible nodule or induration in the posterior area (Koninckx et al., 1996); (ii) dark blue nodule visible at the posterior vaginal wall at speculum examination (Vercellini et al., 1996). DIE was considered histologically-con®rmed when endometrial glands and stroma were present at microscopic examination. We excluded those women who had previously had a DIE nodule resected and those who were no longer menstruating. Variables All the women assessed the severity of their DM, but the method used depended on the study period. During th (...truncated)