1. Endometriosis Max Brinsmead PhD FRANZCOG July 2012

2. Historical Perspective • 1970’s “A disease of uncertain aetiology whose relevance to fertility is uncertain” • 1980’s “A common condition that may be present in as many as one woman in four” • 1990’s Much more known about aetiology. Principles of management emerging. • 2000+ • Evidence-based management

3. Endometriosis is: • Ectopic endometrium i.e. “internal menstruation” • Requires laparoscopy +/- biopsy for diagnosis • Activity is more important than appearance • Symptoms do not always correlate with grading

4. Symptoms of Endometriosis • The Classic Triad… • Dysmenorrhoea • Dyspareunia • Infertility

5. Symptoms of Endometriosis • But consider also… • Pre menstrual staining • Pain with defaecation during menstruation • Intermenstrual pain • Disordered cycles • Family history

6. Diagnosis of Endometriosis • A Careful History (The most important) • Rule out other Causes of Symptoms (The next most important) • Examination (not much help) • Ultrasound (of little value) • MRI (useful for rectovaginal deposits) • Laparoscopy (The gold standard) • Serum CA125 (Lacks sensitivity) • Iridology (a good guess!)

7. Differential Diagnosis: • Primary Dysmenorrhoea • Irritable Bowel Syndrome • Ovulation Pain • Pelvic Inflammatory Disease • Psychosexual Problems

8. Aetiology • Two Main Theories: • Retrograde menstruation • Peritoneal metaplasia • Predisposing Factors • Familial predisposition • Disordered immunity • Environmental toxins • Recurrent ovulation • Infertile partner • Obstructed menstrual flow

9. Principles of Management: • When the Problem is Pain – Use Medical Rx • When the Problem is Infertility – Use Surgical Rx • When there is no Problem – Use no Rx

10. Medical Therapy Options • Progestins • COC (best in continuous form) • Provera or Norethisterone • The Mirena IUS • Danazol & Gestrinone • GnRH agonists +/- Add Back Therapy • A question of side effects

11. Cochrane Conclusions • Oral & rectal Chinese Herbal Medicine better than Danazol in both pain reduction and shrinkage of masses • Auricular acupunture effective in pain relief • Inconclusive evidence that NSAIDs are any better than pacebo • But side effects certainly can occur

12. Cochrane Conclusions(2) • COC as effective as GnRHa in control of dysmenorrhoea 6m after therapy but GNRHa better in terms of dyspareunia • Oral Provera 100 mg daily more effective than placebo (but not Dyhydrogesterone). IM route no better • GnRHa are no more effective than Danazol and side effects are more frequent

13. Cochrane Conclusions(3) • Laparoscopy with diathermy is more effective than just laparoscopy • For up to 12m after for pain • For conception (OR 1.66, CI 1.09-2.51) • There is no advantage from pre operative medical Rx but one small trial showed less pain if a Mirena is provided after surgery (OR 0.14, CI 0.02-0.75) • There is a risk of symptom recurrence if HRT with E2 is used after pelvic clearance