Spotting and endometriosis

Premenstrual spotting of two or more days is strongly associated with endometriosis in women with infertility
Fertility and Sterility
Volume 95, Issue 4, Supplement , Page S15, 15 March 2011.
R.O. Burney, R. Heitmann, G. Chow

Background:
Endometriosis is a debilitating gynecologic condition requiring laparoscopy and histology for diagnosis. The long interval from onset of symptoms to laparoscopy reflects the inaccuracy of symptomatology and the invasiveness of surgical evaluation. Delay in diagnosis may result in disease progression and greater morbidity, whereas a negative laparoscopy subjects the patient to unnecessary surgical risk. Clearly, an accurate means of pre-operatively identifying women with endometriosis is needed. Premenstrual (PM) spotting is defined as the presence of intermittent uterine bleeding on the order of spotting prior to the onset of full menstrual flow.

Objective(s):
To assess the prevalence of endometriosis in infertile women with premenstrual spotting, and to determine the accuracy of this symptom in predicting presence of endometriosis at laparoscopy.

Materials and Method(s):
In this IRB approved study, we reviewed records of infertile women who underwent laparoscopic assessment from August 2007 to May 2010 at a single tertiary center. PM spotting and duration thereof were routinely assessed by questionnaire and intake interview. At least unilateral tubal patency was required for study inclusion. When present, endometriosis stage (rAFS criteria) and lesional phenotype (red vesicular, powder burn, fibrosis) were recorded. Histologic confirmation of endometriosis was conducted in 80% of cases.

Result(s):
Eighty women met study inclusion criteria, and there were no significant differences between the cohorts with respect to age, gravidity, parity or BMI. Compared to women with normal onset of menstrual flow (n =42), women endorsing PM spotting ≥2 days (n = 38) were more likely to have endometriosis (OR = 24.0; 6.1-103.1), advanced stage disease and the red vesicular lesional phenotype. Premenstrual spotting predicted presence or absence of endometriosis with 81% accuracy, and out-performed the traditionally associated symptoms of dysmenorrhea (76%) and dyspareunia (58%) in this regard.

Conclusion(s):
In women with infertility, premenstrual spotting of two or more days is strongly associated with the finding of endometriosis at laparoscopy. Interestingly, PM spotting was associated with the red vesicular lesional phenotype, previously demonstrated to be the most prostaglandin rich subtype. PM spotting may reflect early endometrial sloughing due to inflammation and/or progesterone resistance in women with endometriosis. Studies are underway to investigate the molecular basis for the association between PM spotting and endometriosis-associated infertility.

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