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					  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

-   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
   effect of oestrogen
3. Multiple surgeries and complications to
   bowel, ureter, and bladder
4. Dyspareunia
5. 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

				
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