title: Pelvic pain in women with ovarian endometrioma is mostly associated with coexisting peritoneal lesions.
abstract: OBJECTIVE
  Is the occurrence of pelvic pain in women with ovarian endometrioma associated with coexisting peritoneal lesions (PLs)?
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  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.
  
  
  METHODS
  Retrospective clinical study with case-controlled biological research using prospectively collected tissue samples derived from women with and without endometriosis and their retrospective evaluation.
  
  
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  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.
  
  
  BACKGROUND
  Not applicable.
authors.affiliation: Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan. nemokhan@nagasaki-u.ac.jp
authors.forename: Khaleque Newaz
authors.initials: KN
authors.lastname: Khan
authors.forename: Michio
authors.initials: M
authors.lastname: Kitajima
authors.forename: Akira
authors.initials: A
authors.lastname: Fujishita
authors.forename: Koichi
authors.initials: K
authors.lastname: Hiraki
authors.forename: Ayumi
authors.initials: A
authors.lastname: Matsumoto
authors.forename: Masahiro
authors.initials: M
authors.lastname: Nakashima
authors.forename: Hideaki
authors.initials: H
authors.lastname: Masuzaki
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D015331:Cohort Studies; D051546:Cyclooxygenase 2 / Q000378:metabolism; D015237:Dinoprost / Q000378:metabolism; D004715:Endometriosis / Q000150:complications / Q000276:immunology / Q000503:physiopathology* / Q000601:surgery; D005260:Female; D006801:Humans; D015994:Incidence; D007564:Japan / Q000453:epidemiology; D010535:Laparoscopy; D008264:Macrophages / Q000276:immunology / Q000473:pathology; D008875:Middle Aged; D010049:Ovarian Diseases / Q000150:complications / Q000276:immunology / Q000503:physiopathology* / Q000601:surgery; D017699:Pelvic Pain / Q000453:epidemiology / Q000209:etiology*; D010532:Peritoneal Diseases / Q000150:complications / Q000276:immunology / Q000503:physiopathology* / Q000601:surgery; D011446:Prospective Studies; D012189:Retrospective Studies; D000267:Tissue Adhesions / Q000503:physiopathology; D055815:Young Adult
chemical_list: D015237:Dinoprost; D051546:Cyclooxygenase 2; C496540:PTGS2 protein, human