treatment of en dome trios is

8/14/2019 Treatment of En Dome Trios Is

http://slidepdf.com/reader/full/treatment-of-en-dome-trios-is 1/17

Dr AFROZ KHIZERMCPS TRAINEE



GENERAL TREATMENT ISSUES:It is known to be a recurrent disorder

throughout the whole of reproductive life.Thereare multiple options to treat endometriosis, sopatients decision-making is essential.

Choosing which treatment to have will

depend upon number of factors:-Woman’s age -Fertility status -Nature of symptoms

-Severity of disease -Previous Treatments -Cost+side-effect profile



TREATMENT AIMS:

Treatment aims should be agreed with the

patient.-What are you treating? -Why are you treating? -Possible reasons to treat

-Improve natural fertility -Enhance chances of success at ART -Pain relief as an alternative to surgery -Pain relief while awaiting surgery -Adjunct to surgery -Prophylaxis against disease occurence -Symptom recurrence



How is endometriosis treated?Endometriosis can be treated with medications and/or

surgery. The goals of endometriosis treatment may includepain relief and/or enhancement of fertility.

Non-Hormonal Treatment for Pain

reliefHormonal TreatmentsSurgical treatment



NON-HORMONAL TREATMENT: Includes analgesics which are very

helpful in reducing the severity of dysmenorrhoeaand pelvic pain.Hence,they have no specific impacton the disease and its progression.

However, they do decrease

prostaglandin production, and prostaglandins arewell-known to have a role in production of painsensation.

Analgesics include Non-steroidal anti-inflammatory drugs(NSAIDs),Paracetamol orcodeine.

http://www.medicinenet.com/script/main/art.asp?articlekey=16461

http://www.medicinenet.com/script/main/art.asp?articlekey=16461



HORMONAL TREATMENTS: Since endometriosis occurs during the reproductive

years, many of the available medical treatments forendometriosis rely on interruption of the normal cyclicalhormone production by the ovaries.

Peritoneal lesions decrease in size during therapy butreappear rapidly following therapy.

Endometroimas rarely decrease in size and adhesionswill be unaffected.

The treatments currently available are: Combined oral contraceptives(COC’s)

Danazol Progestogens Gestrinone Gonadotrophin-releasing hormone(GnRH)agonists .



Combined oral contraceptives(COC’s):

Oral contraceptive pills (OCPs) suppress LH and

FSH and prevent ovulation.They also have direct effects on endometrial

tissue, rendering it thin and compact.They do the decidualization of normal and ectopic

endometrium.Should be taken continuously without a break ofseven days.Side effects: weight gain, breast tenderness, nausea, and irregular

bleeding are mild side effects.Oral contraceptive pills are usually well-tolerated inwomen with endometriosis.

.

http://www.medicinenet.com/script/main/forum.asp?articlekey=24750









Danazol(danocrine): It is a synthetic androgen that inhibits leuteinizinghormone (LH) and follicle-stimulating hormone (FSH),

resulting in a relatively hypoestrogenic state.Endometrial atrophy is the likely mechanism in the

relief of pain from endometriosis.Adverse effects related to estrogen defiency

include headache, flushing, sweating and atrophic vaginitis.Androgenic side effects include acne, edema,

hirsutism, deepening of the voice and weight gain.The initial dosage should be 800 mg per day, given in

two divided oral doses, but this dosage can be titrateddown to 200 to 400 mg per day.

Treatment duration is six months but can beextended to nine months in responsive patients with

severe disease.



PROGESTOGENS: These are medroxyprogesterone acetate and

dydogesterone have been given on a continuousbasis to produce pseudo-decidualization of theendometrium and comparable changes inendometriotic lesions.

The dose to be effective is quite high. Side effects:

Include breakthrough bleeding, weight gain,breast tenderness.



GESTRINONE: It is a derivative of 19-nortestosterone.It has slight

androgenic and markedly anti-oestrogenic and anti-progestogenic properties.It interacts with the pituitary steroid receptors and

decreases gonadotrophic secretion resulting indimineshed follicular growth and anovulation.

Dose:A bi-weekly oral dose of 2.5 to 5.0 mg for 6 months

induces amenorrhoea, disappearance of pain andregression of the endometrial deposits.

Side effects:Include weight gain, acne,seborrhoea and mildhirsutism.



GONADOTROPHIC RELEASINGHORMONE(GnRH)AGONISTS:

As effective as danazol.Differ only in there sideeffects. Induce a state of hypogonadotrophic hypogonadismor pseudomenopause with low circulating level ofoestrogen.

They are available as depot injection and nasal

sprays. Side effects include sypmptoms seen at menopause,in particular hot flushes and night sweats.

The low circulating oestrogen levels can affect bone

metabolism.So the long term use can result in reductionin bone mineral density.The administration of low-dose Hormone

replacement therapy(HRT) along with GnRH agonists,socalled “ADD BACK” therapy may offer a way of

preventing the adverse effects of oestrogen deficiency.



SURGICAL TREAMENT:

The goal of surgery is to eliminate all visibleperitoneal lesions,endometriomas,deeplyinfiltrating endometriosis(DIE) and associated

adhesions and to restore normal anatomy.In many cases the patient wishes relief frompain but also desires to retain the possibility offuture pregnancy.In such cases only conservative

surgery can be employed.



CONSERVATIVE SURGERY:Laparoscopic surgery with techniques such

as intra-abdominal lasers has become the standardfor the surgical management of endometriosis.It is now much simpler and safer to

eradicate visible endometriotic lesions with

diathermy,CO2 or Potassium-titanyl-phosphate(KTP) lasers.Likewise, endometriotic cyst can be drained

and opened and the inner cyst wall or lining

destroyed and vaporized with the laser.But in cases where severe adhesions are

found along with endometriomas, open surgery isnecessary.



DEFINITIVE SURGERY: Where there are severe symptoms,or

progressive disease or in women whose familiesare complete,definitive surgery for the relief ofdysmenorrhoea and pain is often necessary.

This takes the form of hysterectomy and

bilateral salpingo-oophorectomy.Definitive surgery is also required for largeadherent endometriomas and for the smallproportion of patients who have deep-seated

endometriosis involving the bowel or bladder.



OVARIAN ENDOMETRIOMAS: Laparoscopic cystectomy is preferable.

If an endometrioma is >4cm before IVF,cystectomy is specifically recommended toconfirm the diagnosis histologically.

When the endometrioma is large, a two-step

procedure should be considered if fertility is tobe conserved; otherwise an oophorectomy shouldbe considered. Two-step procedure:

Marsupializtion and rinsing followed by 3 months GnRH agonist therapy and then repeat surgery.



Surgery for Deeply InfiltratingEndometriosis(DIE): If there is clinical evidence of DIE,possibility

of ureteric,bladder and bowel involvement shouldbe considered pre-operatively to determine thebest management. Therefore,pre-operative assessment isimportant. There should be an intravenouspyelogram(IVP) to detect ureteric strictures and

hydronephrosis and a contrast enema to diagnoseextensive narrowing at the level of rectum orsigmoid. Surgery needs to be performed as safely as

possible and by the most appropriate surgeons.



REFERRENCE:

DEW HURT’S.TEN TEACHERS.

treatment of en dome trios is

Documents