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Endometriosis

Dr.Mona Shroff M.D. Department of Obstetrics and Gynecology SMIMER. Endometriosis. Endometriosis. Definition: Ectopic Endometrial Tissue True Incidence Unknown: ? 1-5% Histology : Endometrial Glands with Stroma +/- Inflammatory Reaction

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Endometriosis

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  1. Dr.Mona Shroff M.D. Department of Obstetrics and Gynecology SMIMER Endometriosis Dr Mona Shroff www.obgyntoday.info

  2. 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. Dr Mona Shroff www.obgyntoday.info

  3. Sites - Pelvic - Extra pelvic • Umbilicus. • Scars (Lap.). • Lungs & plura. • Others. Dr Mona Shroff www.obgyntoday.info

  4. Pelvic Endometriosis • Uterine= Adenomyosis (50%). • Extraut: - Ovary 30% - Pelvic peritoneum 10%. - F. tube. - Vagina. -Bladder & rectum. - Pelvic colon. - Ligaments. Dr Mona Shroff www.obgyntoday.info

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  6. Prevalence

  7. Age at Diagnosis > 45 < 19 3% 36 –45 6% 15% 19 – 25 24% 26 –35 52% Dr Mona Shroff www.obgyntoday.info

  8. Signs and Symptoms • Chronic Pelvic Pain, Dysmenorrhea • Abnormal Uterine Bleeding • Infertility • Deep Dyspareunia • Pelvic Mass (Endometrioma) • Misc: Tenesmus, Hematuria, Hemoptysis Dr Mona Shroff www.obgyntoday.info

  9. 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. Dr Mona Shroff www.obgyntoday.info

  10. 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 Dr Mona Shroff www.obgyntoday.info

  11. Diagnosis • Laparoscopy (“Gold Standard) • Laparotomy • Inconclusive: CA-125, Pelvic Exam, History, Imaging Studies • Biopsy Preferable Over Visual Inspection Dr Mona Shroff www.obgyntoday.info

  12. Appearance Endometriosis May Appear • Brown • Black (“Powderburn”) • Clear (“Atypical”) Endometriosis May Be Associated with Peritoneal Windows Dr Mona Shroff www.obgyntoday.info

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  16. 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 Dr Mona Shroff www.obgyntoday.info

  17. Treatment : Consideration • Age. • Symptoms. • Stage. • Infertility. Dr Mona Shroff www.obgyntoday.info

  18. 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 Dr Mona Shroff www.obgyntoday.info

  19. Dr Mona Shroff www.obgyntoday.info

  20. Pain Management: Medical Therapy • NSAIDs • OCPs (Continuous) • Progestins • Danazol • GnRH-a • GnRH-a + Add-Back Therapy • Aromatase Inhibitors • Misc: Opoids, SSRIs Dr Mona Shroff www.obgyntoday.info

  21. 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. Dr Mona Shroff www.obgyntoday.info

  22. 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 . Dr Mona Shroff www.obgyntoday.info

  23. Aim of the hormonal therapy cont…. (B) Pseudomenopause (induction of amenorrhoea) by: 1. Danazol. 2. Gn RH analogues. 3. Gestrinone. 4. Gossypol. Dr Mona Shroff www.obgyntoday.info

  24. Continuous OCPs • “Pseudopregnancy” (Kistner) • ? Minimizes Retrograde Menstruation • Lower Fertility Rates than Other Medical Treatments • Choose OCPs with Least Estrogenic Effects, Maximal Androgenic / Progestin Effects Dr Mona Shroff www.obgyntoday.info

  25. 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 Dr Mona Shroff www.obgyntoday.info

  26. Danazol • Weak Androgen • Suppresses LH / FSH • Causes Endometrial Regression, Atrophy • Expensive • Side-Effects: Weight Gain, Masculinization, Occ. Permanent Vocal Changes Dr Mona Shroff www.obgyntoday.info

  27. GnRH-a (Leuprolide,triptorelin) • Initially Stimulate FSH / LH Release • Down-Regulates GnRH Receptors–”Pseudomenopause” • Long-Term Success Varies • Expensive • Use Limited by Hypoestrogenic Effects • May be Combined with Add-Back (? >1 Year ) Dr Mona Shroff www.obgyntoday.info

  28. 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 Dr Mona Shroff www.obgyntoday.info

  29. 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 . Dr Mona Shroff www.obgyntoday.info

  30. 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 Dr Mona Shroff www.obgyntoday.info

  31. 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 Dr Mona Shroff www.obgyntoday.info

  32. 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 Dr Mona Shroff www.obgyntoday.info

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