Endometriosis: clinical monitoring and treatment procedures in Rhesus Monkeys

The National Institute on Aging (NIA) sponsored a workshop on September 8, 2004, to discuss the incidence, diagnosis, and clinical treatment of endometriosis in rhesus monkey colonies. Because of the growing number of aging studies using rhesus monkeys, this disease has become more prevalent as monkeys are living into advanced ages in captivity. The objective of the workshop was to gather information from various NIA-supported aging rhesus colonies on the incidence, clinical manifestations, indicators for early detection, and possible treatment options for endometriosis. Participants outlined a course of action for the effective management of this disease that would best maintain the integrity of long-term aging studies.     

Use of leuprolide to treat endometriosis in a rhesus macaque.

Endometriosis was diagnosed in an aged dysmenorrheic rhesus monkey (Macaca mulatta) after biopsy of a 7 cm abdominal mass which could not be completely resected due to extensive adhesions. A 6-month course of treatment with leuprolide, a gonadotropin-releasing hormone agonist, resulted in cessation of menstrual cycles and marked clinical improvement. Dysmenorrhea and hypovolemic shock occurred 2 months after therapy was completed. Despite supportive treatment and resumption of leuprolide, the primate's clinical deterioration and abdominal mass enlargement necessitated euthanasia. To our knowledge, this is the first report of a case of endometriosis in a rhesus macaque treated with a gonadotropin-releasing hormone agonist. Although prolonged leuprolide therapy was clinically effective, its cost and the difficulty in early diagnosis of endometriosis may limit its use in nonhuman primate medicine.     

Ovarian pathology in rhesus macaques: a 12‐year retrospective

Background Ovarian pathology is an important cause of decreased fertility and reproductive capability and may impact multiple systems, particularly in aging rhesus macaques. Methods Retrospective histopathologic and immunohistochemical analysis of 458 female rhesus macaque necropsies over 12 years at the New England Primate Research Center in Southborough, MA. Results Degenerative and inflammatory changes in the ovaries included mineralization, infiltration by lymphocytes, macrophages and multinucleated giant cells, endometriosis, and arteriopathy. Cystic changes included follicular cysts, cystic rete, and mesonephric duct cysts with cystic rete the most common. Neoplasms included granulosa cell tumors, cystadenoma, cystadenocarcinoma, and teratoma. Conclusions Ovarian lesions of the rhesus macaque are similar to those of cynomolgus macaques and humans. These lesions are frequently incidental findings but may impact metabolic and neurocognitive studies.     

Colonic adenocarcinoma in a rhesus macaque (Macaca mulatta)

Abstract: A spontaneous colonic adenocarcinoma and endometriosis was diagnosed in a 34-year-old female rhesus macaque (Macaca mulatta). The tumor caused partial obstruction of the ascending colon and histologically resembled the commonly described napkin-ring tumors of the descending and sigmoid colon found in humans. Serum levels of CA 125, a high-molecular-weight glycoprotein antigen that has been reported elevated in a variety of pathological conditions of the pelvic cavity in humans, was severely elevated. Both the adenocarcinoma and the endometriosis may have contributed to this finding.     

Stromal decidualization of endometriosis in the rhesus macaque (Macaca mulatta): a case report

During exploratory laparotomy, a 10-year-old female rhesus macaque was found to have a 6.0 x 9.5 x 2.0-cm multichambered, yellow, cystic mass cranial to the uterus, from which large amounts of opaque, white fluid were discharged into the abdominal cavity. The animal was euthanized, and the body was submitted for gross and histologic evaluation. Sections of the mass examined microscopically consisted of sheets of polygonal to round cells, with well defined cell borders and moderate amounts of eosinophilic cytoplasm. Scattered throughout these cells were few, variably sized glandular structures composed of columnar to cuboidal epithelium. Glandular epithelial cells were positive for keratin, and the sheets of polygonal cells were positive for vimentin and negative for keratin and CD 68. Gross and histologic appearance, immunohistochemical findings, and history of medroxyprogesterone acetate injections were compatible with a diagnosis of stromal decidualization of endometriosis. Subsequent biopsies of similar lesions in other rhesus macaques in the colony being treated with medroxyprogesterone acetate for endometriosis revealed comparable histologic findings.     

Identification of rhesus macaques with spontaneous endometriosis

Abstract: Rhesus macaques (Macaca mulatta) with endometriosis were identified using reproductive histories, serum levels CA-125, pelvic ultrasonography, laparoscopy, and histopathology. All animals were evaluated from a large breeding colony and had a history of infertility and/or spontaneous abortions. Laparoscopy and ultrasonography were performed on 40 macaques: 27 macaques from the breeding colony with elevated CA-125 levels, ten macaques from the breeding colony with normal or low serum CA-125 levels, and three macaques from another facility with previously diagnosed spontaneous endometriosis. Clinical endometriosis was diagnosed by laparoscopy in 16/37 (43%) macaques from the breeding colony and was confirmed by histologic examination in all animals biopsied. The disease was classified as minimal (40%), mild (25%), moderate (10%), or severe (25%). The most common sites of endometriosis were the serosal surface of the uterus (75%) and the posterior cul-de-sac (75%). In this study, CA-125 levels were useful in identifying animals from the breeding colony with endometriosis. The rhesus macaque provides a valuable animal model to study endometriosis and potentially to assess efficacy of therapeutic agents for this disease condition.     

Record review of baboons with histologically confirmed endometriosis in a large established colony

Spontaneous endometriosis was diagnosed in 43 baboons over a 14-year period. Thirty-seven have died; five remain alive; one was sold and lost to follow-up. The average age at diagnosis was 17.2 years; 29 (67%) were between 12 and 21 years of age. Fifteen (35%) were diagnosed by biopsy and received surgical excision of the endometriotic tissue; four of these were identified during caesarian section, confirming one prior report of endometriosis in pregnant animals. Twenty-eight (65%) were diagnosed at or shortly preceding necropsy. When diagnosed by a palpable abdominal mass, there was a significantly greater likelihood the animal died or was killed as a result of complications of endometriosis. When diagnosis was at necropsy, there was a significantly greater likelihood that the animal died from causes unrelated to endometriosis. Early identification with surgical removal appears to provide a benefit for both survival and delivering offspring after diagnosis. In twenty-one baboons (49%), endometriosis affected multiple sites within the peritoneal cavity. In the remaining baboons, lesions were more localized. Ovarian involvement was seen in sixteen (37%) of these baboons. This paper is the first to describe significant ovarian involvement in baboons, previously considered a limitation of the usefulness of this species as an animal model. We also describe the first reported endometriosis seeding of an abdominal surgery scar in a baboon. Many of these baboons were middle aged, had few or no offspring, or had evidence of a long duration of uninterrupted menstrual cycles, consistent with risk factors for women. Endometriosis was an incidental finding in 17 (40%) of these baboons, consistent with previous reports of minimal endometriosis as a common asymptomatic finding in baboons and in women. Overall, endometriosis in baboons presents a spontaneously occurring animal model that shares important features with the disease in women and the rhesus macaque.     

Radiation-induced endometriosis in Macaca mulatta.

Female rhesus monkeys received whole-body doses of ionizing radiation in the form of single-energy protons, mixed-energy protons, X rays, and electrons. Endometriosis developed in 53% of the monkeys during a 17-year period after exposure. Incidence rates for endometriosis related to radiation type were: single-energy protons, 54%; mixed-energy protons, 73%; X rays, 71%; and electrons, 57%. The incidence of endometriosis in nonirradiated control monkeys was 26%. Monkeys exposed to single-energy protons, mixed-energy protons, and X rays developed endometriosis at a significantly higher rate than control monkeys (chi 2, P less than 0.05). Severity of endometriosis was staged as massive, moderate, and minimal. The incidence of these stages were 65, 16, and 19%, respectively. Observations of clinical disease included weight loss in 43% of the monkeys, anorexia in 35%, space-occupying masses detected by abdominal palpation in 55%, abnormal ovarian/uterine anatomy on rectal examination in 89%, and radiographic evidence of abdominal masses in 38%. Pathological lesions were endometrial cyst formation in 69% of the monkeys, adhesions of the colon in 66%, urinary bladder in 50%, ovaries in 86%, and ureters in 44%, focal nodules of endometrial tissue throughout the omentum in 59%, and metastasis in 9%. Clinical management of endometriosis consisted of debulking surgery and bilateral salpingo-oophorectomy combined in some cases with total abdominal hysterectomy. Postoperative survival rates at 1 and 5 years for monkeys recovering from surgery were 48 and 36%, respectively.     

Alternative Activation of Macrophages in Rhesus Macaques (Macaca mulatta) with Endometriosis

Endometriosis is one of the most frequently encountered gynecologic diseases and a common cause of chronic pelvic pain and infertility. The pathophysiology of this syndrome can best be described as the presence of ectopic endometrium and a pelvic inflammatory process with associated immune dysfunction and alteration in the peritoneal environment. Macrophages play an important role in the progression and propagation of endometriosis. Alternative macrophage activation occurs in rodents and women with endometriosis but had not been examined previously in nonhuman primates. This case–control study aimed to characterize macrophage polarization in the ectopic and eutopic endometrial tissue of nonhuman primates with and without endometriosis. In addition, circulating cytokines in endometriosis cases and normal controls were investigated in an effort to identify serum factors that contribute to or result from macrophage polarization. Endometriosis lesions demonstrated increased infiltration by macrophages polarized toward the M2 phenotype when compared with healthy control endometrium. No serum cytokine trends consistent with alternative macrophage activation were identified. However, serum transforming growth factor α was elevated in macaques with endometriosis compared with healthy controls. Findings indicated that the activation state of macrophages in endometriosis tissue in nonhuman primates is weighted toward the M2 phenotype. This important finding enables rhesus macaques to serve as an animal model to investigate the contribution of macrophage polarization to the pathophysiology of endometriosis.Abbreviations: HLA, human leukocyte antigen; Iba1, ionized calcium binding adaptor molecule 1; M1, classically activated macrophage; M2, alternatively activated macrophage; sCD40L, soluble cluster of differentiation 40 ligand; TGF, transforming growth factor; VEGF, vascular endothelial growth factorEndometriosis is a common cause of chronic pelvic pain and infertility and affects more than 5.5 million women in North America alone.⁴¹ Although endometriosis is one of the most frequently encountered gynecologic health problems among women of reproductive age, the pathophysiology of this disease remains elusive due to its complexity and multifactorial etiology. The presence of functional endometrial glands and stroma outside the uterine cavity defines endometriosis. Currently, the most widely accepted theory for the origin of ectopic endometrial tissue is a combined effect of retrograde menstruation and associated implantation of endometrial fragments at an ectopic site. Progression of endometriosis lesions is thought to then be supported by peritoneal factors that allow cell adhesion and growth.⁴⁴ Although endometriosis is not a neoplastic disease, it exhibits aggressive features such as cellular proliferation, invasion, and vascular proliferation.¹² Strong evidence indicates that endometriosis involves a pelvic inflammatory process, with immune dysfunction and alteration in the peritoneal environment.^13,27 Numerous studies have demonstrated marked increases in macrophage populations and activity in the peritoneum of endometriosis patients.^6,54,59 Although macrophages are integral to homeostasis of the peritoneal environment, during endometriosis they mediate inflammation and facilitate the establishment and maintenance of the disease.Macrophages can be classified into 2 main populations: classically activated macrophages (M1), whose activating stimuli include IFNγ and LPS, and alternatively activated macrophages (M2), whose activating stimuli includes IL4, IL13, IL10, and transforming growth factor (TGF) β.⁵⁵ These polar phenotypes are not expressed together, but the activation state of tissue macrophages can change over time. This phenotypic switch is possible because macrophages retain plasticity, resulting in macrophage polarization that is transient and reversible.⁴⁰ A key component in determining the phenotype of the differentially activated macrophage is their response to microenvironmental signals, and this response allows for expression of a spectrum ranging from the M1 to M2 extremes.⁵¹ M1- and M2-activated macrophages perform different functions by producing pro- or antiinflammatory factors. M1 macrophages have enhanced endocytic functions and an enhanced ability to kill intracellular pathogens; they also secrete large amounts of proinflammatory cytokines such as IL1α, IL6, IL12, and TNFα.⁷ In contrast, M2 macrophages are involved in resolution of inflammation and promotion of tissue repair, and they secrete antiinflammatory and immunosuppressive cytokines including IL10 and TGFβ.³² M2 cells also express proangiogenic factors, such as coagulation factor XIII and vascular endothelial growth factor (VEGF) and have been associated with a high degree of vascularization in vivo.¹ The pathogenesis of endometriosis is therefore a likely combination of inappropriate or sustained polarization, leading to tissue damage (increased M1 response) and immune dysfunction (increased M2 response) and allowing for persistence of ectopic endometrial tissue.The use of animal models in endometriosis research is crucial. Work done with rodents involves the study of induced disease.⁵³ Despite this caveat, rodent models have been the basis for important contributions. Global macrophage depletion in a rat model of endometriosis effectively inhibits the initiation and growth of endometriosis implants.¹⁵ Attenuation of endometriosis has recently also been demonstrated in a mouse model of endometriosis.⁴ In that study, systemic depletion of macrophages was associated with failure of endometrial lesion development and defective angiogenesis of established lesions. Further evaluation of specific roles of differentially activated macrophages in that study⁴ showed that adoptive transfer of alternatively activated macrophages (M2) was associated with enhanced endometriosis progression. Conversely, adoptive transfer of inflammatory macrophages (M1) was associated with abrogated progression. In addition to evaluating murine lesions, the authors of the cited study⁴ investigated markers for alternative macrophage activation in women with endometriosis and matched controls which revealed increased expression of CD163 and CD206 (2 markers of M2 polarized macrophages) in endometriosis lesions as compared with disease-free peritoneum. Although many studies have been published about the pivotal role of macrophages in the pathophysiology of endometriosis, only a few have dealt with activation of the M1 and M2 macrophage phenotypes.^4,57 Furthermore, few studies have examined tissue infiltration of macrophages in eutopic endometrium of human subjects with endometriosis.^6,23 An exhaustive literature search failed to identify studies that investigate the role of M1 and M2 macrophage populations in eutopic endometrium.The current study uses rhesus macaques, which have been studied extensively in reproductive medicine.⁵⁸ Because spontaneous development of the disease requires menstrual shedding, endometriosis occurs naturally only in some nonhuman primate species, making development of lesions more comparable to the establishment of disease in humans.¹⁴ Compared with rodents, the nonhuman primate model of endometriosis is advantageous due to a close recapitulation of human disease and physiology. Work characterizing M1 and M2 macrophage activation in a species with spontaneous disease development may reflect a closer immunologic characterization to humans. In the current study, macrophage populations were evaluated in archival tissue collected from rhesus macaques with a diagnosis of endometriosis as confirmed by histologic examination. To characterize the phenotype of endometrial tissue macrophages in ectopic endometriosis lesions and eutopic endometrium of both cases and controls, immunohistochemistry was used to quantify cells expressing M1- and M2-specific markers. We hypothesized that endometriosis lesions and eutopic endometrium of rhesus macaques would be associated with a polarized macrophage infiltration consisting of increased numbers of M2 macrophages. This increase in M2 response may cause reduced immune clearance of ectopic endometrial cells, facilitating their implantation and growth. Further we speculated that M2 polarization would be associated with increased serum cytokines including IL10 and VEGF and decreased production of IL6, IL12, and TNFα. The lack of findings that support our hypotheses may suggest that the micro- or peritoneal environment is more important for lesion development or that another component of the systemic milieu is the determining factor in the development of endometriosis.     

Endometriosis is associated with progesterone resistance in the baboon (Papio anubis) oviduct: evidence based on the localization of oviductal glycoprotein 1 (OVGP1)

Endometriosis has been associated with a reduced response to progesterone in both the eutopic and ectopic endometrium. In this study we evaluated OVGP1 and steroid receptor expression in oviducts of baboons with endometriosis during the midsecretory phase and determined whether progesterone resistance associated with endometriosis also occurs in the oviduct. Oviducts obtained during the window of uterine receptivity (Day 10 postovulation [PO]) from animals with induced and spontaneous disease were compared to control animals during the proliferative stage and in the implantation window as well as animals treated with the progesterone receptor (PGR) antagonist ZK 137.299 (ZK). OVGP1 was significantly higher in animals with endometriosis compared with Day 10 PO controls and was similar to that seen in the late proliferative phase and in ZK-treated animals. Baboons with spontaneous endometriosis also showed a similar persistence of OVGP1, which was correlated with the maintenance of estrogen receptor 1 (ESR1) in the epithelial cells of animals with endometriosis. However, epithelial cell height and the percentage of ciliation were not affected by endometriosis. These data imply that the normal antagonism of progesterone on ESR and OVGP1, which results in their downregulation during the window of implantation, is absent in animals with endometriosis. This was confirmed further when the action of PGR was antagonized in animals without disease, which also resulted in the persistence of ESR1 and OVGP1. These studies suggest that an aberrant oviductal environment may be an additive factor that contributes to endometriosis-associated infertility.     

Species preference by infant macaques with controlled social experience

In Experiment 1, infant Japanese monkeys and rhesus monkeys were artificially reared in pairs with conspecific or heterospecific monkeys. Preferences of these monkeys for a variety of pictures of Japanese monkeys and rhesus monkeys were repeatedly tested during the first 1 or 2 years of life. The duration of lever-pressing responses to see those pictures was a measure of the preference. All monkeys, Japanese or rhesus, preferred pictures of rhesus monkeys to pictures of Japanese monkeys, without regard to their social experiences. Experiment 2, with an adult Japanese monkey as the subject, and Experiment 3, with different pictures as stimuli, suggested that this preference was not a consequence of any bias in the pictures used. In Experiment 4, a Japanese monkey reared by a rhesus foster mother and rhesus monkeys reared by Japanese monkey mothers received the same preference test. The Japanese monkey infant preferred to see pictures of rhesus monkeys. However, rhesus infants did not show clear species preferences. These results suggest that infants of both Japanese and rhesus monkeys have a native tendency to prefer to see physical characteristics of rhesus monkeys over Japanese monkeys.     

Stimulation of rhesus monkey sperm capacitation by cyclic nucleotide mediators

Capacitation of rhesus monkey spermatozoa was assessed by monitoring sperm flagellar beat and trajectory changes during incubation in vitro and by determining sperm penetration into rhesus oocytes and hamster zona-free ova. Rhesus sperm capacitation in vitro depended on the addition to the culture medium of the cyclic nucleotide mediators, caffeine and dibutyryl cyclic AMP. Capacitation was correlated with the development of hyperactivated motility. Spermatozoa treated with the cyclic nucleotide mediators, and showing hyperactivated motility, penetrated 57.4% of all rhesus oocytes and fertilized 88.9% of mature rhesus oocytes that were morphologically normal. Control spermatozoa did not penetrate any of the eggs. Some sperm penetration into hamster ova occurred but was not statistically significant. These data provide a basis for achieving in-vitro fertilization in the rhesus monkey and information on specific sperm motility characteristics associated with fertilizing ability.     

Cytopathology of peritoneal endometriosis caused by ruptured ovarian cysts

The cytopathologic features of two cases of peritoneal endometriosis (secondary to ruptured ovarian endometrial cysts) are described. Both patients presented with abdominal distension and tenderness and were clinically thought to have an abdominal tumor. Preoperative cytologic examination of peritoneal fluids gave a diagnosis of endometriosis in both cases. The endometrial tissue was present in the smears as honeycombs, syncytia and tight clusters of both epithelial and stromal cells. Subsequent surgery confirmed the cytodiagnosis in both cases. These cases emphasize the need to include endometriosis in the differential diagnosis of peritoneal effusions, especially in women.     

Production and preliminary characterization of monoclonal antibodies directed at two surface proteins of rhesus rotavirus.

A series of monoclonal antibodies was isolated which reacted with one of two major surface proteins of rhesus rotavirus. Thirty-six monoclonal antibodies immunoprecipitated the 82-kilodalton outer capsid protein, the product of the fourth gene, the viral hemagglutinin. These monoclonal antibodies exhibited hemagglutination inhibition activity and neutralized rhesus rotavirus to moderate or high titer. Three monoclonal antibodies immunoprecipitated the 38-kilodalton outer capsid glycoprotein, the eighth or ninth gene product. These three monoclonal antibodies neutralized rhesus rotavirus to high titer and also inhibited viral hemagglutination.     

Carbon monoxide excretion as an index of bilirubin production in rhesus monkeys

The role of increased heme catabolism in neonatal hyperbilirubinemia was investigated in rhesus (Macaca mulatta) neonates through the measurement of carbon monoxide excretion rates (VECO), blood carboxyhemoglobin content (HbCO), and plasma bilirubin concentrations. Neonatal values were compared to those of adult rhesus monkeys. These indices of bilirubin production responded appropriately to administration of NEM-damaged erythrocytes and tin protoporphyrin. Our results indicate that VECO measurements are a valid index of changes in bilirubin production in the newborn rhesus monkey.     

Characterization of periostin expression in human endometrium and endometriotic lesions

Objective(s): To investigate the expression of periostin in the eutopic and ectopic endometrium of women diagnosed as endometriosis and evaluate the role of periostin in the pathogenesis of endometriosis. Study design: In this study, the expression of periostin was evaluated in the endometrial specimens from 35 women diagnosed as endometriosis and from 30 healthy women. To assess the presence and localization of periostin throughout the menstrual cycle in both eutopic and ectopic endometrium of women with endometriosis, microscopic evaluation was conducted. It was also subsequently compared with normal endometrium. Results: In the eutopic and ectopic endometrium of women with endometriosis, immunoreactivities of periostin increased compared with those of normal endometrium. We also observed a cyclic variation in the eutopic stromal periostin immunoreactivity throughout their menstrual cycle because higher H score values were observed in the proliferative phase than those in the secretory phase. Conclusion(s): These findings indicated that periostin may be involved in the pathophysiology of endometriosis.     

Cytokine array analysis of peritoneal fluid between women with endometriosis of different stages and those without endometriosis

Cytokines are key mediators of intercellular communication and are likely to promote the development and progression of endometriosis. Previous studies provided evidence that endometriosis develops as a result of the pathogenetic factors in the peritoneal environment, especially the peritoneal fluid (PF). We determined different cytokine expression in peritoneal fluid between women with minimal/mild and moderate/severe endometriosis and those without endometriosis using the cytokine array. As a result, 78 cytokines were found to have a threefold change, including 74 increases and four decreases in endometriosis compared with the control group; 96 cytokines had a threefold change including 91 increases and five decreases in minimal and mild endometriosis compared with the control group; 83 cytokines had a threefold change including 14 increases and 69 decreases in moderate and severe endometriosis compared with minimal and mild endometriosis. The cytokine networks were produced by Pathway Studio software and revealed that most cytokines are involved in cell binding, interaction and protein synthesis and transportation regulation. Among them activin A, Smad7 and β-nerve growth factor are the most interesting as they may be involved in the pathogenesis of endometriosis. These results suggest that cytokines are very important factors in the development of endometriosis. The findings of differentially expressed cytokines improves our knowledge of the pathogenesis and development of endometriosis and these findings warrant further studies to develop potential targets for the diagnosis and treatment of endometriosis.     

Emerging hallmarks of endometriosis metabolism: A promising target for the treatment of endometriosis

Endometriosis, characterized by ectopic endometrium growth in the extrauterine environment, is one of the most notable diseases of the female reproductive system. Worldwide, endometriosis affects nearly 10 % of women in their reproductive years and causes a significant decline in quality of life. Despite extensive investigations of endometriosis over the past years, the mechanisms of endometriosis pathogenesis remain unclear. In recent years, metabolic factors have increasingly been considered factors in endometriosis. There is compelling evidence regarding the progress of endometriosis in the context of severe metabolic dysfunction. Hence, the curative strategies and ongoing attempts to conquer endometriosis might start with metabolic pathways. This review focuses on metabolic mechanisms and summarizes current research progress. These findings provide valuable information for the non-intrusive diagnosis of the disease and may contribute to the understanding of the pathogenesis of endometriosis.     

Endometriosis and physical exercises: a systematic review

Regular physical exercise seems to have protective effects against diseases that involve inflammatory processes since it induces an increase in the systemic levels of cytokines with anti-inflammatory and antioxidant properties and also acts by reducing estrogen levels. Evidence has suggested that the symptoms associated with endometriosis result from a local inflammatory peritoneal reaction caused by ectopic endometrial implants. Thus, the objective of the present review was to assess the relationship between physical exercise and the prevalence and/or improvement of the symptoms associated with endometriosis. To this end, data available in PubMed (1985–2012) were surveyed using the terms “endometriosis and physical exercises”, “endometriosis and life style and physical exercises” in the English language literature. Only 6 of the 935 articles detected were included in the study. These studies tried establish a possible relationship between the practice of physical exercise and the prevalence of endometriosis. The data available are inconclusive regarding the benefits of physical exercise as a risk factor for the disease and no data exist about the potential impact of exercise on the course of the endometriosis. In addition, randomized studies are necessary.