A Beginner’s Guide to Endometriosis
Back to Medical School 30th March 2006 Mr Martin Glass Consultant Gynaecologist The General Infirmary at Leeds
Introduction and Incidence
A common gynaecological condition
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Proven fertile women: 18% Infertility : 21% Chronic abdominal pain: 15% At sterilisation: 6% At abdominal hysterectomy: 25%
Aetiology
• Unknown • Some familial incidence • Origin:
- retrograde menstruation (75-90% of women at laparoscopy at menstruation) - lymphatic - vascular - peritoneal metaplasia • Adenomyosis
Lesions
• Classic blue-black blisters • Flame-like blisters • Clear nodules • White plaques • Peritoneal defects • Macroscopically normal peritoneum may
have microscopic endometrial glands present
Mechanism of implantation
• ?Altered immune function • ?Abnormalities of cellular adhesion
molecules – Integrins – Extracellular matrix proteins • ?Associated with lack of conception and frequent retrograde menstruation ?
Mechanisms of implantation
• Genetic predisposition to endometrial
implantation • Endometriosis present in women attending for sterilisation is proportional to years since last pregnancy • ? Predisposition to an inflammatory response to cyclical changes which occur in ectopic endometrium
Diagnosis
• The prime symptom of endometriosis is cyclical pain:
- premenstrual - improves with onset of menstruation • Other - deep dyspareunia - infertility - pelvic mass • Adenomyosis is different: - secondary dysmenorrhoea - menorrhagia
Differential diagnosis
• Pelvic inflammatory disease • Ovarian cysts • Irritable bowel • Urinary tract infection • Premenstrual syndrome • PCO syndrome
Diagnostic tests
• Diagnostic laparoscopy (bowel perforation 6 per • • • •
10,000) Operative laparoscopy (bowel perforation 1.3 per 100) Transvaginal ultrasound - to exclude ovarian disease + adenomyosis MRI - may be used to help assess ovarian lesions, pelvic masses and adenomyosis CA 125 / Endometrial antibodies - non-specific
Endometriosis and Pain
Medical Management
• If not wanting to conceive, and no pelvic
mass on examination or ultrasound:
- combined oral contraceptive (monthly or tricycling) - progestogen (Provera 10 mg tds for 90 days) - GnRH analogue ± addback - Danazol (100 mg tds for 3-6 months) - Gestrinone (2.5 mg twice weekly for 6 months)
Endometriosis and Pain
Surgical Management
• Laser ablation + LUNA
- at 6 months: 62.5% improvement vs 22.6% no treatment (Ref. Sutton 1997) - at one year: continued benefit for 90% of responders - poorest outcome: mild disease The problems are incomplete excision and recurrence.
Endometriotic ovarian cysts
• Laparoscopic cystectomy • Drainage and coagulation • Laparotomy • Postoperative GnRH analogue treatment
Mechanisms of infertility in endometriosis
• Deformity of pelvic organs • Alteration of peritoneal environment
- increase in macrophages - decreased sperm motility - phagocytosis of spermatozoa - interference with oocyte pickup
Endometriosis and infertility Medical therapy
• There is no role for medical therapy with
hormonal drugs in the treatment of endometriosis associated with infertility.
Endometriosis and Infertility Surgical treatment
• Laparoscopic ablation of minimal-mild
endometriosis may improve fertility rates. • No improvement other than in minimal or mild cases with IUI and ovarian hyperstimulation.
IVF
• Pregnancy rates significantly lower in the
endometriosis group.
Recommendations
• Severe cases of endometriosis should be
referred to subspecialist • Patient support groups may be helpful
Long-term problems
1. Bilateral oophorectomy 2. Osteoporosis/lack of cardioprotective 3. 4. 5.
effect of oestrogen Multiple surgeries and complications to bowel, ureter, and bladder Dyspareunia Breast and ovarian disease following hormonal treatment
Take-home messages
1. Retrograde menstruation is the probable cause
of most cases 2. The pathophysiology and time course of endometriosis are not fully understood 3. Minimal and mild endometriosis affect fertility and could be treated during the assessment laparoscopy 4. Moderate to severe endometriosis can result in infertility and may require more extensive surgery
Take home messages
5. Medical treatment for endometriosis is
contraceptive, and so is appropriate for patients with pain but not with infertility 6. Surgical treatment of endometriosis can improve the fertility of selected patients 7. Assisted conception technology is often required for women with severe endometriosis 6-12 months following diagnosis 8. Endometriosis following the fertile years can be treated either medically or surgically, but long-term problems exist