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Pelvic congestion/chronic pain dynamics

Pelvic congestion/chronic pain dynamics Human Reproduction Vol.17, No.4 pp. 1127–1132, 2002 Letters to the Editor Pelvic congestion/chronic pain dynamics Overall, the authors appear to believe that the estrogen status and/or sensitivity of pelvic veins is the underlying problem in Dear Sir, PC (Foong et al., 1992). However, neither their results or their discussion support how GnRH agonist-induced effects are main- We read the article by Soysal et al. which was focusing on tained clinically, despite the normalized ovarian function. More- pelvic congestion (PC)/chronic pain (CPP) dynamics with over, how GnRH agonist therapy may be offered cost-effectively interest (Soysal et al., 2001). While reading the article, we in the long-term remains elusive. What is the take home point were confused by the presentation of the methods, results and from the study? Do they recommend adnexectomy and/or hyster- the final conclusion. We do agree with the concept and follow- ectomy to the patients who did improve following GnRH agonist up of the study. If the purpose was to identify PC by venography or intermittent GnRH agonist-only therapy (since HRT given to and all the patients had laparoscopy, what was the sensitivity/ prevent GnRH agonist side-effects, impaired the clinical efficacy specificity of venography among their 148 CPP patients? despite hypoestrogenism)? Furthermore, why were asymptomatic patients used as controls, since they have their internal controls among symptomatic patients (without PC)? Was that group used to test the diagnostic References efficacy of venography? Besides, dealing with vein stability Bausero, P., Ben-Mahdi, M., Mazucatelli, J., Bloy, C. and Perrot-Applanat, and the possible effect of ovarian steroidogenesis on the M. (2000) Vascular endothelial growth factor is modulated in vascular aetiology of PC, the control group should have been age, body muscle cells by estradiol, tamoxifen, and hypoxia. Am. J. Physiol. Heart Circ. Physiol., 279, H2033–H2042. mass index and hormonally matched to avoid selection bias Ceballos, C., Ribes, C., Amado, J.A., Perez, J., Garcia, M.T. and de Berrazuta, (Taskin et al., 1996; Ciardullo et al., 2000). Thus, endogenous J.R. (2000) Venous endothelial function in postmenopausal women who hormonal status of the studied patients had to be compared. are receiving long-term estrogen and progestagen therapy. Fertil. Steril., Although the therapy arm was randomized, a placebo group 74, 268–273. Ciardullo, A.V., Panico, S., Bellati, C., Rubba, P., Rinaldi, S., Ianuzzi, A., or a cross-over design would be better in outlining the Cioffi, V., Iannuzzo, G. and Berrino, F. (2000) High endogenous estradiol associated social/psychological variables/biases, despite is associated with increased venous distensibility and clinical evidence of extensive testing performed, which were indeed subjective. varicose veins in menopausal women. J. Vasc. Surg., 32, 544–549. Foong, L.C., Gamble, J., Sutherland, I.A. and Beard, R.W. (2000) Altered What was the power of the study? The limited study group peripheral vascular response of women with and without pelvic pain due impairs the validity of their conclusion. What was the power to congestion. Br. J. Obstet. Gynecol., 107, 157–164. for such a statistically significant conclusion given in Table IV? Gangar, K.F., Stones, R.W., Saunders, D., Rogers, V., Rae, T., Cooper, S. and How were the hypoestrogenic side-effects of the GnRH Beard, R.W. (1993). An alternative to hysterectomy? GnRH-a combined with HRT. Br. J. Obstet. Gynecol., 100, 360–364. agonist prevented? What were the effects of vasomotor reac- Soysal, M.E., Soysal, S., Vicdan, K. and Ozer, S. (2001) A randomized tion, mood changes and coital problems due to GnRH agonist controlled trial of goserelin and medroxy-progesterone acetate in the on the tests, or how have the authors dealt with these treatment of pelvic congestion. Hum. Reprod., 16, 931–947. confounding factors that may ameliorate their initial evaluation Taskin, O., Uryan, I., Buhur, A., Burak, F., Erden, F., Atmaca, R. and Wheeler, J.M. (1996) The effects of daflon on pelvic pain in women with Taylor following therapy? Syndrome. J. Am. Assoc. Gynecol. Laparosc., 3 (4, Suppl.), S49. Most confusing is the continuing effect of GnRH agonist Wang, Z.H. (1993) Correlation between serotonin and prostaglandins in beyond 12 months, which needs to be explained. If estrogens peritoneal fluid collected from patients with pelvic congestion. Zhonghua. Fu. Chan. Ke. Za Zhi., 28, 337–9, 380. were a possible cause affecting venous distensibility, conges- tion, and mediatory factors, (such as vascular endothelial Omur Taskin, Sinan Kursun, Mehmet Simsek and Bilal Trak growth factor and prostaglandins), causing pain in PC, how Akdeniz University, did the beneficial clinical effects of GnRH agonist persist School of Medicine, despite normal estrogen status (Wang, 1993; Bausero et al., Antalya, Turkey 2000; Ceballos et al., 2000; Ciardullo et al., 2000)? Was an E-mail: omurtaskin@hotmail.com unknown variable, confounding factor or placebo effect missed, or a was psychosocial effect overlooked? Moreover, as reported by Gangar et al. GnRH agonist/hor- mone replacement therapy (HRT) given for 4 months was not effective despite hypoestrogenism (Gangar et al., 1993). In the present study, GnRH agonist given for 6 months without HRT revealed a prolonged effect for 12 months, despite the return of ovarian function. How can this 2 months difference end up with such a significant improvement? If the HRT makes the difference, then how did not much more elevated estradiol levels following GnRH agonist compared with HRT alter the efficacy? © European Society of Human Reproduction and Embryology 1127 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Human Reproduction Oxford University Press

Pelvic congestion/chronic pain dynamics

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Publisher
Oxford University Press
Copyright
© European Society of Human Reproduction and Embryology
ISSN
0268-1161
eISSN
1460-2350
DOI
10.1093/humrep/17.4.1127
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Abstract

Human Reproduction Vol.17, No.4 pp. 1127–1132, 2002 Letters to the Editor Pelvic congestion/chronic pain dynamics Overall, the authors appear to believe that the estrogen status and/or sensitivity of pelvic veins is the underlying problem in Dear Sir, PC (Foong et al., 1992). However, neither their results or their discussion support how GnRH agonist-induced effects are main- We read the article by Soysal et al. which was focusing on tained clinically, despite the normalized ovarian function. More- pelvic congestion (PC)/chronic pain (CPP) dynamics with over, how GnRH agonist therapy may be offered cost-effectively interest (Soysal et al., 2001). While reading the article, we in the long-term remains elusive. What is the take home point were confused by the presentation of the methods, results and from the study? Do they recommend adnexectomy and/or hyster- the final conclusion. We do agree with the concept and follow- ectomy to the patients who did improve following GnRH agonist up of the study. If the purpose was to identify PC by venography or intermittent GnRH agonist-only therapy (since HRT given to and all the patients had laparoscopy, what was the sensitivity/ prevent GnRH agonist side-effects, impaired the clinical efficacy specificity of venography among their 148 CPP patients? despite hypoestrogenism)? Furthermore, why were asymptomatic patients used as controls, since they have their internal controls among symptomatic patients (without PC)? Was that group used to test the diagnostic References efficacy of venography? Besides, dealing with vein stability Bausero, P., Ben-Mahdi, M., Mazucatelli, J., Bloy, C. and Perrot-Applanat, and the possible effect of ovarian steroidogenesis on the M. (2000) Vascular endothelial growth factor is modulated in vascular aetiology of PC, the control group should have been age, body muscle cells by estradiol, tamoxifen, and hypoxia. Am. J. Physiol. Heart Circ. Physiol., 279, H2033–H2042. mass index and hormonally matched to avoid selection bias Ceballos, C., Ribes, C., Amado, J.A., Perez, J., Garcia, M.T. and de Berrazuta, (Taskin et al., 1996; Ciardullo et al., 2000). Thus, endogenous J.R. (2000) Venous endothelial function in postmenopausal women who hormonal status of the studied patients had to be compared. are receiving long-term estrogen and progestagen therapy. Fertil. Steril., Although the therapy arm was randomized, a placebo group 74, 268–273. Ciardullo, A.V., Panico, S., Bellati, C., Rubba, P., Rinaldi, S., Ianuzzi, A., or a cross-over design would be better in outlining the Cioffi, V., Iannuzzo, G. and Berrino, F. (2000) High endogenous estradiol associated social/psychological variables/biases, despite is associated with increased venous distensibility and clinical evidence of extensive testing performed, which were indeed subjective. varicose veins in menopausal women. J. Vasc. Surg., 32, 544–549. Foong, L.C., Gamble, J., Sutherland, I.A. and Beard, R.W. (2000) Altered What was the power of the study? The limited study group peripheral vascular response of women with and without pelvic pain due impairs the validity of their conclusion. What was the power to congestion. Br. J. Obstet. Gynecol., 107, 157–164. for such a statistically significant conclusion given in Table IV? Gangar, K.F., Stones, R.W., Saunders, D., Rogers, V., Rae, T., Cooper, S. and How were the hypoestrogenic side-effects of the GnRH Beard, R.W. (1993). An alternative to hysterectomy? GnRH-a combined with HRT. Br. J. Obstet. Gynecol., 100, 360–364. agonist prevented? What were the effects of vasomotor reac- Soysal, M.E., Soysal, S., Vicdan, K. and Ozer, S. (2001) A randomized tion, mood changes and coital problems due to GnRH agonist controlled trial of goserelin and medroxy-progesterone acetate in the on the tests, or how have the authors dealt with these treatment of pelvic congestion. Hum. Reprod., 16, 931–947. confounding factors that may ameliorate their initial evaluation Taskin, O., Uryan, I., Buhur, A., Burak, F., Erden, F., Atmaca, R. and Wheeler, J.M. (1996) The effects of daflon on pelvic pain in women with Taylor following therapy? Syndrome. J. Am. Assoc. Gynecol. Laparosc., 3 (4, Suppl.), S49. Most confusing is the continuing effect of GnRH agonist Wang, Z.H. (1993) Correlation between serotonin and prostaglandins in beyond 12 months, which needs to be explained. If estrogens peritoneal fluid collected from patients with pelvic congestion. Zhonghua. Fu. Chan. Ke. Za Zhi., 28, 337–9, 380. were a possible cause affecting venous distensibility, conges- tion, and mediatory factors, (such as vascular endothelial Omur Taskin, Sinan Kursun, Mehmet Simsek and Bilal Trak growth factor and prostaglandins), causing pain in PC, how Akdeniz University, did the beneficial clinical effects of GnRH agonist persist School of Medicine, despite normal estrogen status (Wang, 1993; Bausero et al., Antalya, Turkey 2000; Ceballos et al., 2000; Ciardullo et al., 2000)? Was an E-mail: omurtaskin@hotmail.com unknown variable, confounding factor or placebo effect missed, or a was psychosocial effect overlooked? Moreover, as reported by Gangar et al. GnRH agonist/hor- mone replacement therapy (HRT) given for 4 months was not effective despite hypoestrogenism (Gangar et al., 1993). In the present study, GnRH agonist given for 6 months without HRT revealed a prolonged effect for 12 months, despite the return of ovarian function. How can this 2 months difference end up with such a significant improvement? If the HRT makes the difference, then how did not much more elevated estradiol levels following GnRH agonist compared with HRT alter the efficacy? © European Society of Human Reproduction and Embryology 1127

Journal

Human ReproductionOxford University Press

Published: Apr 1, 2002

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