endometriosis
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Dr.Mona Shroff M.D.Department of Obstetrics and Gynecology SMIMER
Dr Mona Shroff www.obgyntoday.info
Endometriosis
Definition: Ectopic Endometrial Tissue True Incidence Unknown: ? 1-5% Histology: Endometrial Glands with
Stroma +/- Inflammatory Reaction Microscopic internal bleeding, with
the subsequent inflammatory response, neovascularization, and fibrosis formation, is responsible for the clinical consequences of this disease.
Dr Mona Shroff www.obgyntoday.info
- Pelvic- Extra pelvic Umbilicus. Scars (Lap.). Lungs & plura. Others.
Dr Mona Shroff www.obgyntoday.info
Uterine= Adenomyosis (50%). Extraut:- Ovary 30%- Pelvic peritoneum 10%.- F. tube.- Vagina.-Bladder & rectum.- Pelvic colon.- Ligaments.
Dr Mona Shroff www.obgyntoday.info
Dr Mona Shroff www.obgyntoday.info
PrevalencePrevalence
Surgical Series (Uncontrolled) 1 – 53%
Surgical Series (Controlled) 23 – 47% (Infertile)1 – 5% (Fertile)
Population-Based Studies 6.2 –7.9%
Epidemiological Study 0.25 new cases/1000woman-years
Prevalence = 7.5%Endometriosis Affects ~5
Million Women, 30-40%are Infertile
Surgical Series (Uncontrolled) 1 – 53%
Surgical Series (Controlled) 23 – 47% (Infertile)1 – 5% (Fertile)
Population-Based Studies 6.2 –7.9%
Epidemiological Study 0.25 new cases/1000w oman-years
Prevalence = 7.5%Endometriosis Affects ~5
Million W omen, 30-40%are Infertile
Age at Diagnosis
< 196%
19 – 2524%
26 –3552%
36 –4515%
> 453%
Dr Mona Shroff www.obgyntoday.info
Signs and Symptoms
Chronic Pelvic Pain, Dysmenorrhea Abnormal Uterine Bleeding Infertility Deep Dyspareunia Pelvic Mass (Endometrioma) Misc: Tenesmus, Hematuria,
Hemoptysis
Dr Mona Shroff www.obgyntoday.info
Pelvic examination may reveal:
1. Pelvic tenderness. 2. Fixed retroverted uterus. 3. Nodularity of the Douglas pouch and
uterosacral ligaments. 4. Ovaries may be enlarged and tender .
Ovarian cyst may be detected.
Dr Mona Shroff www.obgyntoday.info
Etiology: Theories
Sampson: “Retrograde Menstruation” Hematologic Spread Lymphatic Spread Coelomic Metaplasia Genetic Factors Immune Factors Combination of the AboveNo Single Theory Explains All Cases of
Endometriosis Dr Mona Shroff www.obgyntoday.info
Diagnosis
Laparoscopy (“Gold Standard) Laparotomy Inconclusive: CA-125, Pelvic Exam,
History, Imaging Studies Biopsy Preferable Over Visual
Inspection
Dr Mona Shroff www.obgyntoday.info
Appearance
Endometriosis May AppearBrownBlack (“Powderburn”)Clear (“Atypical”)
Endometriosis May Be Associated with Peritoneal Windows
Dr Mona Shroff www.obgyntoday.info
Dr Mona Shroff www.obgyntoday.info
Dr Mona Shroff www.obgyntoday.info
Dr Mona Shroff www.obgyntoday.info
Treatment: Overall Approach
Recognize Goals: – Pain Management– Preservation / Restoration of Fertility
Discuss with Patient:– Disease may be Chronic and Not Curable– Optimal Treatment Unproven or Nonexistent
Dr Mona Shroff www.obgyntoday.info
Treatment : ConsiderationAge.
Symptoms.
Stage.
Infertility.Dr Mona Shroff www.obgyntoday.info
Classification / Staging
Several Proposed Schemes Revised AFS System: Most Often
Used Ranges from Stage I (Minimal) to
Stage IV (Severe) Staging Involves Location and Depth
of Disease, Extent of Adhesions
Dr Mona Shroff www.obgyntoday.info
Dr Mona Shroff www.obgyntoday.info
Pain Management: Medical Therapy NSAIDs OCPs (Continuous) Progestins Danazol GnRH-a GnRH-a + Add-Back Therapy Aromatase Inhibitors Misc: Opoids, SSRIs
Dr Mona Shroff www.obgyntoday.info
Indications of Hormonal Rx
1. Small endometriotic; lesions.2. Recurrence after conservative
surgery.3. Preoperative for 6-12 weeks to
decrease size.4. Postoperative for residual lesions.5. When operation is contraindicated
or refused by the patient.
Dr Mona Shroff www.obgyntoday.info
Aim of the hormonal therapy(A) Pseudopregnancy :1. Combined low - dose contraceptive pills(6 - 18
months to inhibit ovulation and menstruation and induce decidualization to endometriotic tissues).
or2. Progestins (to avoid oestrogen's side effects
medroxy progesterone acetate Depo medroxy progesterone acetate (DMPA) can be given in a dose of 150 mg IM every I - 3 months .
Dr Mona Shroff www.obgyntoday.info
Aim of the hormonal therapy cont….
(B) Pseudomenopause (induction of amenorrhoea) by:
1. Danazol. 2. Gn RH analogues. 3. Gestrinone. 4. Gossypol.
Dr Mona Shroff www.obgyntoday.info
Continuous OCPs
“Pseudopregnancy” (Kistner) ? Minimizes Retrograde Menstruation Lower Fertility Rates than Other
Medical Treatments Choose OCPs with Least Estrogenic
Effects, Maximal Androgenic / Progestin Effects
Dr Mona Shroff www.obgyntoday.info
Progestins
May be as Effective as GnRH-a for Pain Control
MPA 10-30 mg/day, DP 150 mg Semi-Monthly
May be Taken Long-Term Relatively Inexpensive Side-Effects: AUB, Mood Swings, Weight
Gain, Amenorrhea
Dr Mona Shroff www.obgyntoday.info
Danazol
Weak Androgen Suppresses LH / FSH Causes Endometrial Regression,
Atrophy Expensive Side-Effects: Weight Gain,
Masculinization, Occ. Permanent Vocal Changes
Dr Mona Shroff www.obgyntoday.info
GnRH-a (Leuprolide,triptorelin)
Initially Stimulate FSH / LH Release Down-Regulates GnRH
Receptors–”Pseudomenopause” Long-Term Success Varies Expensive Use Limited by Hypoestrogenic Effects May be Combined with Add-Back (? >1
Year )
Dr Mona Shroff www.obgyntoday.info
Aromatase Inhibitors
Blocking the aromatase activity in extraovarian sites that suppress the conversion of androstenedione and testosterone to estrogen. May result in suppression of endometriosis at a local level.
Further studies needed 2.5 mg PO qd for 6 mo; administer
with norethindrone acetate 2.5 mg PO qd
Dr Mona Shroff www.obgyntoday.info
Gestrinone It is a synthetic 19 Nor steroid exhibits
marked and - progcs-terogenic and anti - oestrogenic as well as mild androgenic and anti -gonadotrophic properties .
The endocrine effects of Gestrinone are similar to those of Danazol which leads mainly to inhibition of ovari an steroidogenesis .
The dose is 2.5 - 5 mg orally twice weekly .
Dr Mona Shroff www.obgyntoday.info
Surgical Treatment (Laparoscopy / Laparotomy)
Excision / Fulgration(ELECTROCAUTRY/LASER) Resection of Endometrioma Lysis of Adhesions, Cul-de-sac Reconstruction Uterosacral Nerve Ablation Presacral Neurectomy Appendectomy Uterine Suspension (? Efficacy) Hysterectomy +/- BSO
Dr Mona Shroff www.obgyntoday.info
Issues
? Removal of Ovaries at Hysterectomy
? Need for Progestins if ERT Given ? Adjuvant Treatment Postoperatively ? Lupron Challenge Test for Diagnosis ? Is Endometriosis Best Treated
Surgically, Medically or Both
Dr Mona Shroff www.obgyntoday.info
Conclusion
Endometriosis is a Common, Chronic Disease
Typical Symptoms Include Pain, Infertility, Abnormal Uterine Bleeding
The Optimal Treatment Remains Unclear Surgical Excision is the Most Efficacious
Approach with Respect to Fertility Better Medical Therapies are Needed
Dr Mona Shroff www.obgyntoday.info
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