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Endometriosis

Endometriosis. Incidence. 6-10% of reproductive age women Present in up to 75% of patients with chronic pelvic pain Present in 40% of women with infertility FH of 1 st degree relative increases risk 10 fold Etiology. Manifestations. Dysmenorrhea Chronic pelvic pain Dysparunia

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Endometriosis

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  1. Endometriosis

  2. Incidence • 6-10% of reproductive age women • Present in up to 75% of patients with chronic pelvic pain • Present in 40% of women with infertility • FH of 1st degree relative increases risk 10 fold • Etiology

  3. Manifestations • Dysmenorrhea • Chronic pelvic pain • Dysparunia • Uterosacral nodularity • Adenexal mass • Infertility

  4. Diagnosis • Laparoscopy is only definite diagnostic test • Confirmed 80% of the time if clinically suspected • Appropriate to treat with only a clinical diagnosis

  5. Surgical Treatment • Hysterectomy with BSO has a failure rate of 5% • Hysterectomy w/o BSO has a 2/3 recurrence rate and 1/3 rate of repeat surgery • Laparoscopic conservative surgery shows 60% improvement in pain and 40%recurrence with in 2 years • Not clear if fertility improved by surgery

  6. Medical Treatment • First line is OCPs either cyclic or continuous with or without NSAIDS • Second line is • Depo Provera 150mg x 3 mon • GNRH agonists with or with out add back • Danazol 400-600mg/d x 3-6 mon

  7. GNRH agonists • Leuproline (Lupron) IM 3.75-7.5mg/m or 11.25mg/3m for 3-6 month

  8. Add Back Therapy • Purpose is relieve hotflashes and limit bone loss • Start after 0-3 months of GNRH agonist therapy • No difference in effectiveness of treatment for endometriosis • Use any form of HRT (estrogen + progestin) in lowest dose to control hotflashes

  9. Treatment Flow Sheet

  10. Miscellaneous Topics • Value of treatment in improving fertility in mild disease is not established • Combination surgery followed by medical therapy (OCP or Depoprovera) results in best pain relief • Ovarian endometriomas should be managed surgically • Mirena, continuous OCP, Depoprovera

  11. 48 y/o s/p TAH for fibroids • CC: RLQ pain sudden onset 8 out of 10 • PI: Present to ER with severe pain w/o fever, chills, nausea or vomiting, no constipation or diarrhea

  12. VS: P=110, BP 135/85, afebrile • Abdomen: diffusely tender especially in the RLQ, with mild rebound • Pelvic exam: Cx, uterus absent, bimanual bulging tender firm mass felt vaginally

  13. CBC: Hb 12.5, WBC 11,000 normal diff • CMP normal, UA normal • CT: 9.5x6.7 cm multicystic right ovarian lesion, small amount of nonspecific pelvic fluid, appendix normal

  14. Returned a few hours later still in pain • WBC 14,000 with left shift • Sent to U of I ER/Gyn department

  15. U of I ER/gyn saw her, did tumor markers, and released her • Ultrasound in my office: 9.5x5.5 complex, ?hemorrhagic cystic mass with no blood flow • Consulted with U of I gyn who said tumor markers were negative

  16. U of I did 23 hr stay releasing her on BCP, po dilaudid, and follow up in 2 weeks

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