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János ARANYOS I MD.

János ARANYOS I MD. What is endometriosis?. Endometriosis occurs when tissue like that which lines the inside of uterus grows outside the uterus, usually on the surfaces of organs in the pelvic and abdominal areas, in places that it is not supposed to grow.

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János ARANYOS I MD.

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  1. János ARANYOS I MD.

  2. What is endometriosis? • Endometriosis occurs when tissue like that which lines the inside of uterus grows outside the uterus, usually on the surfaces of organs in the pelvic and abdominal areas, in places that it is not supposed to grow The word endometriosis comes from the word “endometrium”

  3. In what places, outside of the uterus, do areas of endometriosis grow? • Most endometriosis is found in the pelvic cavity: • On or under the ovaries • Behind the uterus • On the tissues that hold the uterus in place • On the bowels or bladder • Myometrium, vagina, perineum • In extremely rare cases, endometriosis areas can grow in the lungs, nose or other parts of the body

  4. Typical sites of endometriosis

  5. When do we have to think of endometriosis ? • ENDOMETRIOSIS should be considered in women who develop DYSMENORRHEA after years of pain-free cycles.

  6. Symptoms of endometriosis One of the most common symptoms of endometriosis is pain, mostly in the abdomen, lower back, and pelvic areas. The amount of pain a woman feels is not linked to how much endometriosis she has. Some women have no pain even though their endometriosis is extensive, meaning that the affected areas are large, or that there is scarring. Some women, on the other hand, have severe pain even though they have only a few small areas of endometriosis.

  7. General symptoms of endometriosis • Extremely painful (or disabling) menstrual cramps; pain may get worse over time • Chronic pelvic pain (includes lower back pain and pelvic pain) • Pain during or after sex - dyspareunia • Intestinal pain • Painful bowel movements or painful urination during menstrual periods • Heavy menstrual periods • Premenstrual spotting or bleeding between periods • Infertility In addition, women who are diagnosed with endometriosis may have gastrointestinal symptoms that resemble a bowel disorder, as well as fatigue.

  8. Generalized pelvic pain Pelvic inflammatory diseaseEndometritisPelvic adhesionsNeoplasms, benign or malignantOvarian torsionSexual or physical abuseNongynecologic causes Dysmenorrhea Primary Secondary (adenomyosis, myomas, infection, cervical stenosis) Dyspareunia Musculoskeletal causes (pelvic relaxation, levator spasm) Gastrointestinal tract (constipation, irritable bowel syndrome) Urinary tract (urethral syndrome, interstitial cystitis) Infection Pelvic vascular congestion Diminished lubrication or vaginal expansion because of insufficient arousal Infertility Male factor Tubal disease (infection) Anovulation Cervical factors (mucus, sperm antibodies, stenosis) Luteal phase deficiency Differential Diagnosis of Endometriosis by Symptom

  9. Who gets endometriosis? • Endometriosis can affect any menstruating woman, from the time of her first period to menopause, regardless of whether or not she has children, her race or ethnicity, or her socio-economic status. • Endometriosis can sometimes persist after menopause; or hormones taken for menopausal symptoms may cause the symptoms of endometriosis to continue

  10. Prevalence of endometriosis • CURRENT ESTIMATES: • 2 PERCENT • 10 PERCENT • of women of reproductive age • statistics can vary widely

  11. Endometriosis – Infertility ? • 30 percent to 40 percent of women with endometriosis are infertile • unprotected sex for 6-12 months before any treatment for the endometriosis • Relation between endometriosis and infertility: • Uterus does not accept embryo • Endometriosis changes the egg • Endometriosis gets in the way of moving a fertilized egg to the uterus

  12. Pathogenesis of endometriosis • Exact cause is unknown – numerous theories • Retrograde menstrual flow • Genes: inherit, genetic errors, „ectopic” development(specific gene related to endometriosis has not been found yet) • Müllerian remnants can differentiate into endometrial tissue • Estrogen promotes the growth of endometriosis • Disease of the immune system(menstrual fluid is not completely eliminated from the pelvic cavity) • Environmental agents, chemicals, chr. infection • Peritoneal epithelium can be "transformed" into endometrial tissue

  13. Diagnosis • History, symptoms, familiar background • Physical, bimanual, pelvic, rectal examination: -early menses:implants are laergest and most tender • Nodules, cysts: Ultrasound, CT, MRI • Surgical: Laparoscopy, Laparotomy: direct visualisation • Biochemical: Ca-125 ? differentiate • Histological: BIOPSY during surgery

  14. Endometriosis of the Fallopian tube

  15. Characteristic appearance of endometriosis • PLAQUE • NODULE-NODE • CYST • FLUID IN THE PELVIC CAVITY • MIXED ABDOMINAL APPEARANCE

  16. Endometriotic plaque

  17. Nodular endometrial lesions in the posterior cul-de-sac

  18. Endometriosis of the Douglas

  19. Staging: operative procedure • LOCATION • DIAMETER • DEPTH • DENSITY of adhesions • Stages range from minimal to severe • Despite this standardization, the correlation between stage and extent of disease remains controversial.

  20. Staging of endometriosis

  21. Extensive endometriosis in the ovarian fossa - petechial appearance

  22. Treatment • Expectant • OCP, Progesteron • Medical • Surgical:-advanced

  23. Treatment • Because no pharmacologic method appears to restore fertility, medical treatment for endometriosis should be reserved for use in patients with pain or dyspareunia. • pregnancy is contraindicated in patients receiving medical treatment • drugs that are used interfere with ovulation

  24. DRUG DOSAGE COST ADVERSE EFFECT

  25. Treatment: OCP, Progesterone • alleviate symptoms in about 75% of patients • continuously or cyclically • discontinue after six to 12 months • suppress LH and FSH • prevent ovulation • direct effects on endometrial tissue, rendering it thin and compact • decidualization of endometrial implants • lower menstrual volume

  26. Hemorrhagic lesions overlying the right ureter

  27. Treatment: Danazol • effective in relieving the symptoms of endometriosis • synthetic androgen that inhibits leuteinizing hormone (LH) and follicle-stimulating hormone (FSH) • relatively hypoestrogenic state • Endometrial atrophy 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

  28. Treatment: Danazol • Danazol therapy should be started when the patient is menstruating • The initial dosage should be 800 mg per day, given in two divided oral doses • Dosage can be titrated down as long as amenorrhea persists and pain symptoms are controlled • Treatment duration is six to nine months • Overall response rate is 84 to 92 percent • Beneficial effects lasting up to six months after treatment has stopped

  29. Treatment: GNRHGoNadotropin Releasing Hormone 1. • Agonists or analogues • leuprolide [Lupron], gosarelin [Zoladex]) • inhibit the secretion of gonadotropin and are comparable to danazol in relieving pain • sending the body into a “menopausal” state • hypoestrogenic side effects • produce a mild degree of bone loss • condition reverses after the medication is discontinued„add back” low dose estrogen therapy

  30. Treatment: GNRHGoNadotropin Releasing Hormone 2. • Leuprolide is a single monthly 3.75-mg depot injection given intramuscularly • Gosarelin, in a dosage of 3.6 mg, is administered subcutaneously every 28 days • Nasal spray (nafarelin [Synarel]) is also available and is used twice daily • Response rate is similar to that with danazol; about 90 percent of patients experience pain relief • Pregnancy rate after the use of these agents is no different from that in untreated patients

  31. Endometriosis of the ovary

  32. Treatment: SURGERY 1. • The usefulness of conservative surgery for pain relief is unclear, but it appears that immediate postoperative efficacy is at least as high as with medical treatment, and long-term outcomes may be considerably higher • Laparoscopy is much more expensive than medical treatment, however, causing some physicians to argue that overall costs can be reduced by aggressive use of empiric treatments before surgery is considered • Definitive surgery, which includes hysterectomy and oophorectomy, is reserved for use in women with intractable pain who no longer desire pregnancy • In less severe cases, one ovary may be retained to preserve ovarian function, although improvement will be less definitive

  33. Treatment: SURGERY 2. • preferred approach to infertile patients with advanced endometriosis • benefit of surgery in these patients may be due entirely to the mechanical clearance of adhesions and obstructive lesions • endometrial lesions are cystic or nodular and can be excised • hemorrhagic or petechial and amenable to laser obliteration • recent randomized, controlled study involving 341 infertile women with minimal or mild endometriosis demonstrated a 13 percent absolute increase in the probability of pregnancy in a 36-week period • Infertile patients with documented endometriosis can benefit from the same reproductive techniques (e.g., superovulation, in vitro fertilization) that are used in other infertile patients

  34. Treatment: Laparoscopy • The goal is to treat the endometriosis without harming the healthy tissue around it • Laparoscopy: - Confirm, staging, biopsy, - Removal of endometriosis areas - Excision - Electrocoagulation - Thermocoagulation - Laser vaporisation

  35. Laparoscopic excision of nodular endometrial lesions overlying the rectum.

  36. Ovary with endometrioma

  37. Laser may be used to obliterate endometrial implants

  38. Cystic implants adjacent to the right ovary; note bluish appearance

  39. Treatment: Infertility Superovulation In vitro fertilization and embryo transfer

  40. Treatment:Major abdominal surgery, or laparotomy • During laparotomy, doctors either remove the endometriosis and/or remove the uterus • may also remove the ovaries and fallopian tubes at the time of a hysterectomy, if the ovaries have endometriosis on them, or if damage is severe • If a woman’s pain is extreme, doctors may recommend more drastic procedures that cut the nerves in the pelvis to lessen the pain. One such procedure can be done during either laparoscopy or laparotomy. Another procedure, called a laparoscopic uterine nerve ablation (LUNA) is done during a laparoscopy. • These procedures cannot be reversed

  41. Huge „chocolate cyst” of the ovary

  42. Treatment Disadvantages Advantages

  43. Medical management of endometriosis

  44. Thank You!

  45. Sites of endometriosis

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