{"paper_id":"f5afb7a8-839c-4e8d-9a6b-b55221460dc3","body_text":"ORIGINAL ARTICLE\nEndometriosis in the African American woman —racially,\na different entity?\nGeorge H. Shade & Mieke Lane & Michael P. Diamond\nReceived: 28 April 2011 / Accepted: 31 May 2011 / Published online: 24 June 2011\n# Springer-V erlag 2011\nAbstract Endometriosis has been identified in up to 10%\nof women in some reports; however, few studies have\nevaluated African American women. The purpose of this\nstudy was to localize the implantation sites of endometri-\nosis in urban Detroit female patients. This study was a\nretrospective chart analysis of patients with laparoscopes\nfor endometriosis at St. John Detroit Riverview Hospital in\nDetroit, Michigan. All women had concomitant disease\ninvolving the uterus and multiple genital structures. In total,\n93% had uterine implants, 62% had ovarian implants, 51%\nhad posterior cul-de-sac disease, and 44% had fallopian\ntube involvement. Forty-five percent had abdominal wall\nspread, 8% with large bowel implants, and 13% with small\nbowel involvement. Fifty percent had uterosacral implants,\n2% had bladder involvement, 2% had perihepatic involve-\nment, and 4% had omental implants. African American\nwomen appear to have a predilection for uterine implants\nof endometriosis, which may be due to genetic, environ-\nmental, or previously presented theories. Further study of\nurban African American females is necessary to investigate\nthe departure from typical sites of endometriotic implant\nlocalization.\nKeywords African American . Endometriosis .\nImplantation . Uterus\nBackground\nEndometriosis, which is the pathologic localization of\nendometrial glands and stroma at non-endometrial and\nmyometrial locations, will forever be linked to Dr. Sampson\nand his well-known theory of retrograde menses as its\netiology in 1921. Since then, the study of endometriosis has\nevolved immensely. However, one area where research of\nendometriosis still needs to improve is in the study of this\ndisease process in the urban African American female.\nIn reviewing the current literature, there are only two\narticles that are devoted to endometriosis and the African\nAmerican woman. Both of those articles were written by\nDr. Donald Chatman in 1975 and 1976. His focus was to\nprove the chief complaint of abdominal pain in the African\nAmerican female was not typically pelvic inflammatory\ndisease, as was so often labeled in the Emergency Depart-\nments, but was indeed endometriosis [ 1, 2]. A recent report\nhowever showed that among women presenting for infer-\ntility care, African American women were significantly\nmore likely to have salpingitis than non-African Americans;\nhowever, in this report, endometriosis was only identified in\n2.6% of 77 African American women [ 3].\nIn Chatman’s papers, he states that the implants he found\nwere visualized in the typical locations including the\nuterosacral ligaments, cul-de-sac, and ovarian surfaces. We\npropose that although African American women have typical\nimplantation sites, they may have a higher preponderance of\nG. H. Shade : M. P . Diamond (*)\nDepartment of Obstetrics and Gynecology, Wayne State\nUniversity/Detroit Medical Center,\n60 West Hancock Street,\nDetroit, MI 48201, USA\ne-mail: mdiamond@med.wayne.edu\nM. Lane\nCascadia Women’s Clinic,\nV ancouver, W A, USA\nGynecol Surg (2012) 9:59 –62\nDOI 10.1007/s10397-011-0685-5\n\natypical sites including the uterus. This may be explained\nby genetic factors, environmental influences, or previous\npresented theories.\nMaterials and methods\nThis retrospective chart review was conducted at St. John\nDetroit Riverview Hospital in Detroit, MI. The study was\napproved by the Institutional Review Board of St. John\nDetroit Riverview. The target population included African\nAmerican women with a known diagnosis of endometriosis\nwho had a laparoscopy performed by one of us (GS) over\nthe time period of 1995 –2002. These included women\nundergoing surgery indicated because of pelvic pain,\nmasses, and/or infertility. This represents all women whose\ncharts were able to be located from an archival storage\nfacility. The basis for the diagnosis of endometriosis was\nlaparoscopic pictures, which were available for review in\n56% of the charts, while in the remaining patients, the\nlocations of the endometriotic implants were taken directly\nfrom the chart. Histologic confirmation was not required.\nThe study parameters included were age, parity, age of\nmenarche, age of diagnosis of severe pain, number of\nemergency room visits, race, surgical history, treatment\nhistory, and pelvic adhesions. There were 44 patients\nidentified who met these criteria.\nFindings\nAmong the population group of African American women,\nthe age range for the participants was 17 –57, with a mean\nage of 38.9 years. The mean age of menarche was 11.9 years\nin the 31 women with a documented age for menarche. The\nmean age of severe pain was 31 years of age. The average\ngravida and para were G2.4 and P 1.9. CA-125 was\nobtained in ten of the patients; two were found to be\nelevated. As far as prior therapies, 8 had previously\nreceived Provera, 17 had received Lupron, 5 had received\noral contraceptives, and 1 patient had received Danocrine.\nThree women had documented cases of pelvic inflamma-\ntory disease.\nRegarding the surgical management history, these\nwomen had a variety of procedures. Twenty-one patients\nhad a total of 32 laparoscopies. Eighteen had undergone\nhysterectomies, five had myomectomies, and three had\nprior adnexal surgery. Additionally, one woman under-\nwent an endometrial ablation procedure, while another\nhad undergone hysteroscopy.\nThe proportion of patients found to have uterine\nimplants was overwhelming, occurring in 93% of subjects.\nThe women who were found to have uterine implants also\nhad adhesions that affected other pelvic organs. It was\nfound that 39% of patients had posterior uterine implants\nonly, 2% had anterior implants only, 20% had both anterior\nand posterior uterine implants, and 32% had uterine\nimplants that were not designated as anterior or posterior.\nThus, a total of 93% had uterine endometriotic implants.\nAdditionally, there were 62% of patients with ovarian\nimplants, 51% with posterior cul-de-sac disease implants,\nand 44% with fallopian tube involvement. Forty-five\npercent had abdominal wall spread, 8% with large bowel\nimplants, and 13% with small bowel involvement. Fifty\npercent had uterosacral implants, 2% with bladder involve-\nment, 2% with perihepatic involvement, and 4% with\nomental implants. There was one patient with a prior\nhistory of endometriosis that had no endometriotic lesions\nidentified at the time of her laparoscopy.\nDiscussion\nIn this retrospective study, the objective goal was to examine\nthe sites involved with endometriosis. Traditionally, the most\ntypical site for implantation of endometriosis has been the\ndependent portions of the pelvis, including the uterosacral\nligaments, posterior cul-de-sac, and ovaries. While these sites\nwere frequently involved in this study population, it was\noverwhelmingly found that the most common site for\nimplants was the uterus. There was a greater predilection of\nthe implants to attach to the posterior uterus vs. the anterior\nuterus. This suggestion of a possible racial difference in\ncharacteristics of endometriosis is consistent with a prior\nreport of an increased incidence in Asian women as\ncompared to Caucasian women [ 4], as well as the more\nr e c e n tr e p o r to fe n d o m e t r i o s i si n1 7A f r i c a nA m e r i c a n\nwomen in whom the rate of diagnosis was 40% lower than\nCaucasian women [ 5].\nEstablishing this pattern of occurrence raises the\nquestion as to why this may occur. There may be a\nvariety of reasons why, but first, it is important to review\nthe history of implantation theories. The embryonic rest\ntheory developed by V on Recklinghausen and Russell in\n1890 proposed that a nonspecific stimulus activated cells\nof mullerian origin at rest to differentiate into endome-\ntrium. In 1919, Meyer postulated that endometriosis\ndevelops from metaplasia of coelomic epithelium, from\nwhich the mullerian duct is derived in embryonic\ndevelopment. Sampson in 1921 further attempted to\nexplain the genesis of endometriosis by proposing the\ntheory of retrograde menstruation. It is well accepted\ntoday that an amalgamation o f these, and other theories,\nrepresents the multiple o rigins of endometriosis.\nAlthough the origin of endometriosis in African Amer-\nican women may be the same, there are multiple possible\n60 Gynecol Surg (2012) 9:59 –62\n\nreasons for this discrepancy. First would be genetic-based\nvariation, although candidate genes responsible for the\ndifference are not identified or readily apparent. The\ndominant site of implantation in our population was not.\nOne possibility could be hypothesized as an immunologic\ndifference. For example, women with endometriosis have\nbeen documented to have increased number of peritoneal\nleukocytes. These leukocytes secrete growth factors and\ncytokines that promote proliferation of endometriosis.\nNatural killer cells (NKC) have also been intensely studied\nas a part of this immune deregulation in women with\nendometriosis [ 6]. It has been shown that NKCs are\nsuppressed in women with endometriosis, which would\naffect the body ’s ability to adequately remove ectopic\nendometrium. The two main areas that may influence the\nAfrican American female disease state are environment and\nimmunology.\nAlternatively, differences seen may not represent a\ngenetic variation but rather be a function of socioeconomic\nor environmental issues of Detroit. In major metropolitan\nareas such as Detroit, African Americans predominately\nlive in an urban setting rather than a rural environment.\nLiving primarily in an urban setting presents its own unique\nsocial issues that reflected in the environment. Issues such\nas clean water, availability of adequate nutrition, and\naccessibility to health care are all of concern.\nThe impact of adequate nutrition is a significant one in\nDetroit. It was recently named one of the most overweight\ncities in the USA. To be classified as obese, the body mass\nindex (BMI) must be greater than 30; in this study, 36%\nwere obese.\nWomen with higher BMIs tend to have higher levels of\nestrogen, as a function of aromatization of androgens into\nestrogens in adipose tissue. One hypothesis is that there\nmay be a correlation with uterine endometriotic implants\nand African American with obesity secondary to the\nestrogen receptors in the uterine tissue [ 7]. The higher the\nBMI, the more estrogen.\nHowever, obesity does not explain all of the cases of\nendometriosis in this population. Another possible issue\nwould include the exposure to environmental toxicants.\nOne of the major environmental toxins that have been\nstudied is 2,3,7,8-tetrachlorodibenzo-p-dioxin, otherwise\nknown as dioxin. Dioxins are a part of the polychlorinated\ndiaromatic hydrocarbons, which are unwanted by-product\nof many industrial and combustion processes. This toxin\ndegrades slowly, builds up in the food chain, and is ingested\nby humans. It is known that dioxin can inhibit ovarian\nprogesterone synthesis and can have antiestrogenic effects.\nA study by Bois et al. [ 8] reviewed residents in a town in\nItaly who were exposed to a chemical plant explosion that\ninvolved dioxin. His study was conducted in response to a\nstudy by Rier et al. [ 9] that looked at dioxin exposure in\nmonkeys, and found that monkeys exposed to high levels of\ndioxin were prone to develop endometriosis. Bois et al. [ 9]\nrevealed that dioxin is stored in adipose tissue and\nconcluded that this particular Italian community had an\nincreased risk of developing endometriosis. Thus, in\ngeneral, humans may develop endometriosis based on the\nlevel of exposure to dioxin, or perhaps other organochlorine\ncompounds. However, the relationship of dioxin to endo-\nmetriosis remains controversial, as exemplified by the\nrecent report of Guo et al. [ 10], questioning the existence\nof significant evidence supporting such a link.\nDetroit is known as the motor city secondary to its vast\nindustry of auto production. There are also a multitude of\nother industries present in the Detroit area. In our study\nbased on African American population, there is potential\nexposure to dioxins or other agents. Exposure may be via\ningestion of contaminated water, air, and/or food supply.\nSince dioxin is indeed stored in fat, the hypothesis for\nuterine implants may be the same as above for obesity.\nEnvironmental factors may also influence the immuno-\nlogical system. Dysregulation within the immune system\nmay promote the growth of endometriosis. Halme et al. [ 11]\nshowed that women with endometriosis have an increased\nnumber of macrophages, which could have altered\nresponses to retrograde construction products, although\nthe specific mechanism for promotion of endometriotic\nlesions is unclear.\nGazvani et al. [ 12] discussed a strong role for the\nsystem’s immune cells and mediators in the pathogenesis of\nendometriosis. Our population may have an altered immune\nsystem secondary to the urban environment in which they\nwere raised in and/or currently live. The resulting deregu-\nlated immune system may contribute to the higher\npropensity of uterine implants in this group of women [ 3].\nWe acknowledge the limitations of this study include the\nlimited number of participants that comprised the popula-\ntion [ 13], the lack of histological confirmation to make the\ndiagnosis of endometriosis, the lack of a comparable\nDetroit Metropolitan population of non-African American\nwomen, and the non-controlled factor of incomplete ability\nto obtain charts from an archival storage facility. Nonethe-\nless, we believe the observation of an apparent difference in\nthe location of endometriotic implants in African American\nwomen, as compared to previously described populations,\nwarrants future systematic examination.\nConcl\nusion\nIn the end, these African American women appear to have a\nhigher predisposition to uterine endometriotic implants.\nReasons may include environmental, lifestyle, and/or\nimmunological factors or a combination of the various\nGynecol Surg (2012) 9:59 –62 61\n\nfactors. This study reveals the need to have further\ninvestigation into this important subject.\nStatement of Responsibility George H. Shade, M.D. provided\nclinical care for these patients and contributed to the initial concept\nof the study, data analysis, interpretation, writing and critical review of\nthe manuscript.\nMieke Lane, D.O. conducted the chart review and contributed to\nthe initial concept of the study, data analysis, interpretation, writing\nand critical review of the manuscript.\nMichael P . Diamond, M.D. contributed to the initial concept of the\nstudy, data analysis, interpretation, writing and critical review of the\nmanuscript.\nDeclaration of interest The authors report no conflicts of interest. The\nauthors alone are responsible for the content and writing of the paper.\nReferences\n1. Chatman DL (1976) Endometriosis and the black woman. J\nReprod Med 16(6):303 –306\n2. Chatman DL (1976) Endometriosis in the black woman. Am J\nObstet Gynecol 125(7):987 –989\n3. 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Kyama MC, D'Hooghe TM, Debrock S, Machoki J, Chai DC,\nMwenda JM (2004) The prevalence of endometriosis among\nAfrican-American and African- indigenous women. Gynecol\nObstet Invest 57(1):40 –42\n62 Gynecol Surg (2012) 9:59 –62","source_license":"CC0","license_restricted":false}