**7. References**

488 Endometriosis - Basic Concepts and Current Research Trends

women with infertility can take advantage of this type of treatment. However, the total decline in myoma volume and controlling symptoms are greater in GnRHa protocol (Ichigo *et al*, 2011). The benefit of dienogest in controlling symptoms may persist after therapy of GnRHa in

In the previous study (Imai *et al*, 2003*)*, because rapid regrowth frequently occurs after the therapy is stopped. we attempted to determine whether GnRHa therapy could lead perimenopausal women carrying symptomatic myomas to the natural onset of the menopause. A retrospective analysis of 145 patients who received GnRHa for 24 weeks demonstrated that after cessation of therapy no menstruation occurred over 25 weeks in women aged over 45 years, with elevated levels of follicle-stimulating hormone (FSH) and luteinising hormone (LH). To extend this observation, we studied prospectively 21 women, aged 45 years and older who had regular menstruation with symptoms attributed to myomas and elevated days 3 - 5 FSH and days 3 - 5 LH levels (> 25 mIU/ml). After discontinuation of GnRHa (leuprorelin acetate, 1.88 mg) therapy for 6 months, menstruation occurred in only two of 21 individuals but the remaining 19 cases had no menstrual bleeding. It is suggested that the rise in early follicular phase serum gonadotrophins, in particular FSH (> 25 mIU/ml), may precede the natural menopause following (or during) GnRHa therapy in older women. Measuring days 3 to 5 serum FSH concentrations may make it easier to decide on the optimal duration of therapy for symptomatic uterine fibroids in perimenopausal women aged > 45 years. However, in other words, approximately 10 %

Regarding an unexpected event of case 7 of table 1, she has no known previous history of pelvic inflammatory disease, IUD, or any surgical intervention, so she was very unlikely to present with ovarian abscess. It shows that an isolated ovarian abscess can develop in an endometrioma without any recognized risk factor. There are different theories about developing an abscess in the endometrioma (Hameed *et al*, 2010; Kavoussi *et al*, 2006). It may be due to an altered immune environment within endometrial glands and stroma. Recent studies have shown that progesterone-like substances enhance the sexual transmission of various pathogens, including bacteria (Huber & Gruber, 2001; Vassiliadou *et al*, 1999). Collection of altered menstrual type of blood in a cystic space in the ovary and can be a suitable culture medium for pathogens. Cystic wall of endometrioma is theoretically weak

as compared to normal ovarian epithelium, so it is susceptible to bacterial invasion.

Lastly, we reported successful management of a series of patients with uterine myoma associated with endometriosis by sequential therapy with GnRHa and a progestine dienogest, although based on the finding in patients associated with endometriosis. The follow-up period of our study was too short to consider the recurrence rate of myomas after discontinuation of treatment in all subjects. Although prospective controlled study should be addressed, the use of dienogest treatment following GnRHa discontinuation for perimenopausal women with symptomatic uterine myoma or adenomyosis should be

High recurrence rate rapidly after finishing GnRHa leads us to examine the efficacy of sequential management with GnRHa and dienogest in perimenopausal women with endometrisosis-associated uterine myoma. Consideration of GnRHa advantages on myoma

perimenopausal women.

of women failed to become natural menopause.

considered before choosing a more invasive interventions.

**5. Conclusion** 


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