Title: Endometriosis
1Endometriosis
- Dr. Hima Kandimalla
- Mount Hope Womens Hospital
- Trinidad Tobago
2Endometriosis
- Presence of endometrial glands stroma outside
the endometrial cavity and uterine musculature
3Endometriosis
- Epidemiology
- Globally 90 million suffering with Endometriosis
- Prevalence 3-10 of reproductive age group
25-35 of infertile women - Peak incidence 30-45 yrs of age
- Prevalence is similar in all races
4Endometriosis
5Endometriosis
- Pathogenesis
- Implantation or Metastatic theory - Sampson, 1927
- Retrograde menstruation
- More common in young girls with
- genital outflow obstruction
- Physiological phenomenon
- Halme et al, AJOG, 1984
6Endometriosis
- Retrograde menstruation
- ? Contributing factors
- 1. Alteration in the Endometrium
- 2. Altered Immune response
- 3. Favorable Peritoneal environment
- Mechanical Endometriotic foci in surgical scars
- Lymphatic or Hematogenous Extragenital locations
7Endometriosis
- Metaplasia theory Meyer, 1919
- Metaplastic changes in coelomic membrane towards
endometrial like tissue following prolonged
irritation or Oestrogen stimulation
8Endometriosis
- Genetic, Immunological environmental factors
- 7 times more common in 1relatives
- Halme et al, 1986 Sampson et al 1980
- More common in Monozygotic twins than in
Dizygotic twins Simpson et al, 1984 - Decreased cellular immunity to endometriotic
tissue - Dmowski et al, 1981 - ? Dioxins Endometriosis association, 1993
9Endometriosis
Mechanical
Immunological
Genetic
Endocrine
Implantation
Metaplasia
Endometrial implant
Progression invasion
Lymphatic Blood spread
Adapted Modified from R.W. Shaw, Gynecology
10Endometriosis
- Pathology
- Puckered black lesions
- White scarring
- Red polyps
- Clear blebs
11White plaques Clear vesicles
Blue-black lesions
Newly formed blood vessels
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13Endometriosis
- Pathology
- Endometrioma
- Contains blood, fluid menstrual debris
- Brown to black color due to Hemosiderin
14Endometriosis
- Pathology
- Microscopy
- Endometrial glands stroma
- Often contain fibrous tissue, blood cysts
15Endometriosis
- Stromal endometriosis
- Implants contain only stromal component without
glandular part - Not hormonal dependent
- Locally malignant
16Endometriosis
Staging American society of Reproductive
Medicine, 1996
Stage I Minimal Isolated superficial
implants, No adhesions
Stage II Mild More superficial implants (lt5cm),
No significant adhesions
17Endometriosis
Staging American society of Reproductive
Medicine, 1996
Stage III Moderate Multiple superficial
invasive implants, Peritubal Periovarian
adhesions may be present
Stage IV Severe Multiple implants, Ovarian
endometriomas, Many dense adhesions
18Endometriosis
Staging American society of Reproductive
Medicine, 1996
- Staging is designed to predict the likelihood of
future fertility - There is no correlation between the stage of
disease the degree of pain or the prognosis
with treatment
19Endometriosis
- Diagnosis
- Often misdiagnosed
- The average time to diagnosis is 9.28 years
- Endometriosis association study, 1998
- Delay in diagnosis
- - Progression of symptoms
- - ? Infertility till complete reproductive
failure
20Endometriosis
Symptoms
- Reproductive organs
- Dysmenorrhoea
- Lower abdominal, pelvic low back pain
- Menstrual irregularities
- Infertility
21Endometriosis
Symptoms
- GIT
- Cyclical rectal bleeding
- Tenesmus
- Dyschesia
- Diarrhea/ Cyclic constipation
- Image courtesy of Dr. Andrew Cook. Visit his
site Endometriosis
22Endometriosis
Symptoms
- Urinary tract
- Cyclical hematuria
- Cyclical dysuria
- Ureteric obstruction
23Endometriosis
Symptoms
- Lungs
- Cyclical hemoptysis
- Blood stained Pleural effusions
- Catamenial Pneumothorax
Haemothorax ascites associated with
endometriosis.- Charran D, Roopnarinesingh
S.Department of Obstetrics and Gynaecology,
U.W.I., Trinidad.West Indian Med J. 1993
Mar42(1)40-1.
24Endometriosis
Symptoms
- Umbilicus Surgical scars
- Cyclical pain swelling
25Endometriosis
Symptoms
26Endometriosis
- Signs
- Pelvic tenderness.
- Fixed retroverted uterus.
- Nodularity of the Douglas pouch and uterosacral
ligaments. - Ovaries may be enlarged and tender . Ovarian cyst
may be detected.
27Endometriosis
- Infertility
- Clear association with infertility has not been
established - Incidence of endometriosis in general population
of reproductive age 2-10 - - Barbieri et al, 1990
- Incidence of endometriosis in infertile women
20-40 - Mahmood et al, 1990
28Endometriosis
- Infertility
- In early stages
- ? Activated macrophages in peritoneal fluid
- ? PG, IL-1, TNF proteases in peritoneal fluid
- ? levels of anti-endometrial antibodies
- Luteal phase dysfunction
- Abnormal follicle growth
- Multiple premature LH surges
- LUF syndrome
29Endometriosis
- Infertility
- In advanced stages
- Pelvic adhesions impairs ova release, blocks
sperm entry into the peritoneal cavity inhibits
tubal pickup of the oocyte
30Endometriosis
- Risk of cancer
- Ovarian Clear cell Endometrial cell carcinomas
- Breast cancer, Melanoma NHL
- - Endometriosis Association study, 1998
31Endometriosis
- Differential diagnosis
- Pelvic infection
- Uterine Myomas
- Ovarian malignant tumors with metastatic deposits
in the pouch of Douglas - Acute abdomen
- Rectal carcinoma
32Endometriosis
Investigations Laparoscopy Gold standard
diagnostic test for endometriosis It permits a
see treat approach, although its
effectiveness may be limited by the nature of the
disease and the surgeon's skill
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34Endometriosis
- Investigations
- Serum CA 125
- Sensitivity 28 specificity 90
- - Mol BW et al, Fertil Steril, 1998
- Not useful for screening, because of poor
sensitivity - Can be used to identify a sub-group of women who
are likely to benefit from early laparoscopy to
follow the progress of disease after establishing
the diagnosis
- Cheg YM et al, Obst Gyn, 2002
35Endometriosis
Investigations Ultrasound Sensitivity for focal
endometrial implants is poor
36Endometriosis
- Investigations
- Ultrasound
- For Endometriomas sensitivity 83 specificity
98
37Endometriosis
- Investigations
- CT scan
- Endometriomas may appear solid, cystic or mixed
- Because of poor specificity high radiation, CT
has been replaced by MRI
38Endometriosis
- Investigations
- MRI
- Role is limited in visualizing small
endometriotic implants and adhesions - More useful for lesions in extraperitoneal
locations the contents of pelvic mass - More frequently used in staging treatment
response monitoring
39Endometriosis
- Treatment
- Consider
- Age
- Symptoms
- Stage
- Infertility
40Endometriosis
- Treatment
- Rationale
- Recognize Goals
- Pain Management
- Preservation / Restoration of Fertility
- Discuss with Patient
- Disease may be Chronic and Not Curable
- Optimal Treatment Unproven or Nonexistent
41Endometriosis
- Lines of management
- Expectant
- Medical
- Hormonal
- Surgical
42Endometriosis
- Expectant management
- Young , asymptomatic infertile patient with mild
endometriosis. - If pregnancy does not achieved within 12 - 18
months of observation, hormonal or surgical
treatment is indicated .
43Endometriosis
- Medical Treatment
- Symptomatic pts with minimal or mild lesions
- NSAIDs
- Opioids.
44Endometriosis
- Hormonal Treatment
- Produces pseudo pregnancy or pseudo menopause
- Danazol
- Progestins
- Gestrinone
- Combined oestrogen-progestogen Pills
- GnRH agonists.
45Endometriosis
- Hormonal Treatment
- Indications
- Small superficial lesions
- Recurrence after conservative surgery
- Preoperative for 6-12 wks to decrease size
- Postoperative for residual lesions
- When surgery is contraindicated or refused by the
patient. - Enometriosis in Rectovaginal septum laparotomy
scars doesnt respond to Hormonal therapy
46Endometriosis
- Danazol
- Isoxazole derivative of 17 alpha ethinyl
testosterone - Causes anovulation by
- Attenuating the mid cycle surge of LH
- Inhibiting multiple enzymes in steroidogenic
pathway - ? Testosterone levels
- Dose 400 800 mg/ day for 6 months
- Adverse effects Androgenic effects, effects on
serum lipids, ? Bone mineral density Liver
damage
47Endometriosis
- Progestational drugs
- Causes endometrial decidualization atrophy
- Medroxyprogesterone (Provera) is commonly used
- Dose 20-30 mg/ day for 6 -9 months
- Adverse effects Abnormal uterine bleeding,
nausea, breast tenderness, fluid retention
depression
48Endometriosis
- Gestrinone (Ethylnorgestrienone)
- Antiprogestational steroid causes ? estrogen
progesterone receptors - Dose 5-10 mg/ wk - dly or twice a wk or 3 times
a wk, for 6-9 months - Adverse effects deepening of voice, hirsuitism
Clitorial hypertrophy
49Endometriosis
- Combined pills
- Well tolerated can be continued for long term
- 1 pill/ day either continuously or cyclically
- Continuous regimen is superior in patients with
dysmenorrhea - Adverse effects weight gain, abnormal bleeding
HTN
50Endometriosis
- GnRH agonists
- ? FSH LH results in endometrial atrophy
amenorrhea - Intranasally or SC or IM with a frequency of
twice dly to once in 3 months up to 3 - 6 months - Adverse effects transient vaginal bleeding, hot
flushes, vaginal dryness, ? libido, breast
tenderness, insomnia, depression, irritability,
fatigue, headache, osteoporosis, ?
elasticity of skin - GnRH agonists Add-back therapy (estrogens
progestogen) less side-effects but with same
efficacy, can be continued beyond 6 months
51Endometriosis
Hormonal Treatment The choice between the
COCPs, Progestogens, Danazol GnRH agonists
depends principally upon their side-effect
profiles because they relieve pain associated
with endometriosis equally well - Clinical Green
Top Guidelines, 2000
52Endometriosis
- Surgical management
- Conservative Excision, Cauterization
Evaporation - Surgeries for pain - Uterosacral Nerve Ablation
(LUNA), Presacral Neurectomy - Radical surgeries - Hysterectomy /- BSO
- Surgeries for Endometrioma Cystectomy, Drainage
coagulation, Fenestration
53Endometriosis
- Surgical management
- Laparotomy Vs Laparoscopy
- Efficacy is same
- Laparoscopy less cost shorter recovery time
even in women with advanced endometriosis
54Endometriosis
- Laparoscopic management
- 1. Excision
- 2. Vaporization
- 3. Fulguration Desiccation
- 4. Cystectomy for endomterioma
- 5. Drainage Coagulation for endometrioma
- 6. Fenestration for endometrioma
- No RCTs available to compare these procedures
- Cystectomy offer better results than drainage
coagulation for Endometrioma - If no cyst wall is present, Fenestration followed
by GnRH agonists may prove beneficial
55Endometriosis
Laparoscopic management
56Surgical management
- outcome was poorest in minimal endometriosis
- much better in moderate severe cases
- - Sutton CJ et al, Fertil Steril 1994
57Endometriosis
- Combination of Hormonal Surgical
- Postoperative Danazol Medroxyprogesterone for 6
months lowered the pain scores significantly
Telimaa S et al, Gynecol Endo, 1987 - Postoperative GnRH agonist for 6 months lowered
the recurrence rates but with no change in pain
scores Parazzini F et al, AJOG, 1994 - Sufficient data is not available to conclude that
hormonal surgical combination is associated
with significant benefits. The possible benefits
should be weighed in the context of the adverse
effects costs of these therapies - - Cochrane review, May 2004
58Endometriosis
- Infertility Management
- No role for medical therapy with hormonal drugs
- Laparoscopic ablation of minimal mild
endometriosis may improve fertility rates - - Cochrane review, 2004
59Endometriosis
- IUI
- The presence of endometriosis does not generally
impair the results of IUI - Ovarian hyperstimulation using Gonadotrophins
with IUI is better than no treatment or IUI alone - Nulsen Jc et al, Obst Gyn, 1993
- Tummon IS et al, Fertil Steril, 1997
60Endometriosis
Pelvic pain suspected Endometriosis
Continue drug therapy
NSAID or OCP
Success
Failure
Empirical GnRH agonist Estro Prog add-back
therapy
Operative Laparoscopy
Continue Drug therapy
Failure
Success
GnRH agonist Estro Prog add-back therapy
61Endometriosis
Infertility Suspected endometriosis
Operative Laparoscopy
Assisted Reproduction
Watchful waiting
Success
Pregnancy
Failure
62Endometriosis
- Conclusion
- Endometriosis is a mystery tour as it requires
decision making at every stage by the physician
and the patient. - Endometriosis still stand as one of the
most-investigated disorders in gynecology. So is
one of the highest priorities for research.
63Thank you