Endometriosis

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Endometriosis

• Dr.Mona Shroff M.D.
• Department of Obstetrics and Gynecology
• SMIMER

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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.

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Sites

• - Pelvic
• - Extra pelvic
• Umbilicus.
• Scars (Lap.).
• Lungs plura.
• Others.

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Pelvic Endometriosis

• Uterine Adenomyosis (50).
• Extraut
• - Ovary 30
• - Pelvic peritoneum 10.
• - F. tube.
• - Vagina.
• -Bladder rectum.
• - Pelvic colon.
• - Ligaments.

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Prevalence
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Age at Diagnosis
gt 45
lt 19
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36 45
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15
19 25
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26 35
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Signs and Symptoms

• Chronic Pelvic Pain, Dysmenorrhea
• Abnormal Uterine Bleeding
• Infertility
• Deep Dyspareunia
• Pelvic Mass (Endometrioma)
• Misc Tenesmus, Hematuria, Hemoptysis

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Signs

• 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.

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Etiology Theories

• Sampson Retrograde Menstruation
• Hematologic Spread
• Lymphatic Spread
• Coelomic Metaplasia
• Genetic Factors
• Immune Factors
• Combination of the Above
• No Single Theory Explains All Cases of
  Endometriosis

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Diagnosis

• Laparoscopy (Gold Standard)
• Laparotomy
• Inconclusive CA-125, Pelvic Exam, History,
  Imaging Studies
• Biopsy Preferable Over Visual Inspection

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Appearance

• Endometriosis May Appear
• Brown
• Black (Powderburn)
• Clear (Atypical)
• Endometriosis May Be Associated with Peritoneal
  Windows

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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

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Treatment Consideration

• Age.
• Symptoms.
• Stage.
• Infertility.

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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

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Pain Management Medical Therapy

• NSAIDs
• OCPs (Continuous)
• Progestins
• Danazol
• GnRH-a
• GnRH-a Add-Back Therapy
• Aromatase Inhibitors
• Misc Opoids, SSRIs

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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.

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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).
• or
• 2. 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 .

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Aim of the hormonal therapy cont.

• (B) Pseudomenopause (induction of amenorrhoea)
  by
• 1. Danazol.
• 2. Gn RH analogues.
• 3. Gestrinone.
• 4. Gossypol.

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Continuous OCPs

• Pseudopregnancy (Kistner)
• ? Minimizes Retrograde Menstruation
• Lower Fertility Rates than Other Medical
  Treatments
• Choose OCPs with Least Estrogenic Effects,
  Maximal Androgenic / Progestin Effects

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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

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Danazol

• Weak Androgen
• Suppresses LH / FSH
• Causes Endometrial Regression, Atrophy
• Expensive
• Side-Effects Weight Gain, Masculinization, Occ.
  Permanent Vocal Changes

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GnRH-a (Leuprolide,triptorelin)

• Initially Stimulate FSH / LH Release
• Down-Regulates GnRH ReceptorsPseudomenopause
• Long-Term Success Varies
• Expensive
• Use Limited by Hypoestrogenic Effects
• May be Combined with Add-Back (? gt1 Year )

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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

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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 ovarian steroidogenesis .
• The dose is 2.5 - 5 mg orally twice weekly .

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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

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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

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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