Endometriosis - PowerPoint by niusheng11

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									Endometriosis

Dr. Hima Kandimalla
 Mount Hope Women’s Hospital
      Trinidad & Tobago
         Endometriosis
Presence of endometrial glands & stroma
   outside the endometrial cavity and
          uterine musculature
               Endometriosis

Epidemiology

• Globally 90 million suffering with
  Endometriosis
• Prevalence: 3-10% of reproductive age
  group & 25-35% of infertile women
• Peak incidence: 30-45 yrs of age
• Prevalence is similar in all races
        Endometriosis
sites
                   Endometriosis
Pathogenesis
Implantation or Metastatic theory - Sampson, 1927
Retrograde menstruation
•   More common in young girls with
    genital outflow obstruction
•   Physiological phenomenon
      – Halme et al, AJOG, 1984
               Endometriosis

• Retrograde menstruation
  ? Contributing factors
      1. Alteration in the Endometrium
     2. Altered Immune response
     3. Favorable Peritoneal environment
• Mechanical – Endometriotic foci in surgical scars
• Lymphatic or Hematogenous – Extragenital locations
            Endometriosis

Metaplasia theory – Meyer, 1919

  Metaplastic changes in coelomic membrane towards
  endometrial like tissue following prolonged
  irritation or Oestrogen stimulation
                    Endometriosis
    Genetic, Immunological & environmental factors
•   7 times more common in 1°relatives
                         – Halme et al, 1986 & Sampson et al 1980
•   More common in Monozygotic twins than in
    Dizygotic twins                          – Simpson et al, 1984
•   Decreased cellular immunity to endometriotic
    tissue                                   - Dmowski et al, 1981

•   ? Dioxins                  – Endometriosis association, 1993
                   Endometriosis
Mechanical        Endocrine              Immunological              Genetic


         Implantation                                  Metaplasia


                        Endometrial implant



                              Progression &
                                 invasion


                              Lymphatic &
                              Blood spread

                                Adapted & Modified from – R.W. Shaw, Gynecology
              Endometriosis

Pathology

• Puckered black
  lesions
• White scarring
• Red polyps
• Clear blebs
             White plaques &
              Clear vesicles




Blue-black
 lesions
                          Newly formed
                          blood vessels
               Endometriosis

Pathology
Endometrioma
• Contains blood, fluid &
  menstrual debris
• Brown to black color due
  to Hemosiderin
               Endometriosis

Pathology
Microscopy
• Endometrial glands &
  stroma
• Often contain fibrous
  tissue, blood & cysts
             Endometriosis
Stromal endometriosis

• Implants contain only stromal component
  without glandular part
• Not hormonal dependent
• Locally malignant
          Endometriosis
Staging
– American society of Reproductive Medicine, 1996


    Stage I – Minimal
    Isolated superficial implants,
    No adhesions




      Stage II – Mild
      More superficial implants (<5cm),
      No significant adhesions
            Endometriosis
   Staging
   – American society of Reproductive Medicine, 1996



Stage III – Moderate
Multiple superficial & invasive implants,
Peritubal & Periovarian adhesions may be present




 Stage IV – Severe
 Multiple implants,
 Ovarian endometriomas,
 Many dense adhesions
                     Endometriosis
Staging
– American society of Reproductive Medicine, 1996


• Staging is designed to predict the likelihood of
  future fertility
• There is no correlation between the stage of
  disease & the degree of pain or the prognosis
  with treatment
                 Endometriosis
Diagnosis
• Often misdiagnosed
• The average time to diagnosis is 9.28 years
                        – Endometriosis association study, 1998
• Delay in diagnosis:
  - Progression of symptoms
  -  Infertility till complete reproductive failure
               Endometriosis
Symptoms

Reproductive organs
• Dysmenorrhoea
• Lower abdominal, pelvic
  & low back pain
• Menstrual irregularities
• Infertility
                Endometriosis
Symptoms


GIT
•   Cyclical rectal bleeding
•   Tenesmus
•   Dyschesia
•   Diarrhea/ Cyclic
    constipation

• Image courtesy of Dr.
  Andrew Cook. Visit his
  site: Endometriosis
              Endometriosis
Symptoms


Urinary tract
• Cyclical hematuria
• Cyclical dysuria
• Ureteric obstruction
                 Endometriosis
Symptoms


Lungs
• Cyclical hemoptysis
• Blood stained Pleural
  effusions
• Catamenial
  Pneumothorax
    Haemothorax & ascites associated with endometriosis.
                 - Charran D, Roopnarinesingh S.
     Department of Obstetrics and Gynaecology, U.W.I., Trinidad.
             West Indian Med J. 1993 Mar;42(1):40-1.
               Endometriosis
Symptoms


Umbilicus & Surgical
 scars
• Cyclical pain &
  swelling
               Endometriosis
Symptoms

  • Dysmenorrhoea                  60-80%
  • Pelvic pain                    30-50%
  • Infertility                    30-40%
  • Dyspareunia                    25-40%
  • Menstrual irregularities       10-20%
  • Cyclical dysuria / hematuria    1-2%
  • Dyschesia                       1-2%
  • Cyclic Rectal bleeding          <1%
               Endometriosis

Signs
• Pelvic tenderness.
• Fixed retroverted uterus.
• Nodularity of the Douglas pouch and uterosacral
  ligaments.
• Ovaries may be enlarged and tender . Ovarian cyst may
  be detected.
                   Endometriosis
Infertility
• Clear association with                 40


  infertility has not been               35


  established                            30


• Incidence of endometriosis in
                                         25


  general population of                  20


  reproductive age : 2-10%               15


                - Barbieri et al, 1990
                                         10


• Incidence of endometriosis in
                                         5


  infertile women: 20-40%
                                         0
                                              Normal   Infertile

              - Mahmood et al, 1990
                 Endometriosis
Infertility
In early stages:
•    Activated macrophages in peritoneal fluid
•    PG, IL-1, TNF & proteases in peritoneal fluid
•    levels of anti-endometrial antibodies
•   Luteal phase dysfunction
•   Abnormal follicle growth
•   Multiple premature LH surges
•   LUF syndrome
                Endometriosis

Infertility
In advanced stages:
• Pelvic adhesions impairs ova release, blocks sperm
  entry into the peritoneal cavity & inhibits tubal pickup
  of the oocyte
             Endometriosis

Risk of cancer

• Ovarian Clear cell & Endometrial cell
  carcinomas
• Breast cancer, Melanoma & NHL
                     - Endometriosis Association study, 1998
              Endometriosis
Differential diagnosis

• Pelvic infection
• Uterine Myomas
• Ovarian malignant tumors with metastatic
  deposits in the pouch of Douglas
• Acute abdomen
• Rectal carcinoma
                  Endometriosis
Investigations
Laparoscopy
‘Gold standard’ diagnostic
    test for endometriosis
It permits a “see & treat”
    approach, although its
    effectiveness may be
    limited by the nature of
    the disease and the
    surgeon's skill
                 Endometriosis
Investigations
                            I    19
Serum CA 125
                            II   40
                           III   77
                           IV    182    - Cheg YM et al, Obst Gyn, 2002

• Sensitivity 28% & specificity 90%
                                 - Mol BW et al, Fertil Steril, 1998
• Not useful for screening, because of poor sensitivity
• Can be used to identify a sub-group of women who
  are likely to benefit from early laparoscopy & to
  follow the progress of disease after establishing the
  diagnosis
                 Endometriosis
Investigations
Ultrasound
  Sensitivity for focal
  endometrial
  implants is poor
                 Endometriosis
Investigations
Ultrasound

For Endometriomas
  sensitivity 83% &
  specificity 98%
                 Endometriosis
Investigations
CT scan
• Endometriomas may
  appear solid, cystic or
  mixed
• Because of poor
  specificity & high
  radiation, CT has been
  replaced by MRI
                  Endometriosis
Investigations
MRI
• Role is limited in visualizing
  small endometriotic implants
  and adhesions
• More useful for lesions in
  extraperitoneal locations & the
  contents of pelvic mass
• More frequently used in staging
  & treatment response
  monitoring
                Endometriosis
Treatment
Consider
• Age
• Symptoms
• Stage
• Infertility
              Endometriosis
Treatment
Rationale
• Recognize Goals:
 –   Pain Management
 –   Preservation / Restoration of Fertility
• Discuss with Patient:
 –   Disease may be Chronic and Not Curable
 –   Optimal Treatment Unproven or Nonexistent
           Endometriosis

Lines of management

•   Expectant
•   Medical
•   Hormonal
•   Surgical
              Endometriosis
Expectant management

• Young , asymptomatic infertile patient with mild
  endometriosis.
• If pregnancy does not achieved within 12 - 18
  months of observation, hormonal or surgical
  treatment is indicated .
               Endometriosis

Medical Treatment
Symptomatic pts with minimal or mild lesions
•   NSAIDs
•   Opioids.
                 Endometriosis
Hormonal Treatment

Produces pseudo pregnancy or pseudo menopause
•   Danazol
•   Progestins
•   Gestrinone
•   Combined oestrogen-progestogen Pills
•   GnRH agonists.
                Endometriosis
Hormonal Treatment
Indications
•   Small & superficial lesions
•   Recurrence after conservative surgery
•   Preoperative for 6-12 wks to decrease size
•   Postoperative for residual lesions
•   When surgery is contraindicated or refused by the
    patient.
Enometriosis in Rectovaginal septum & laparotomy scars
  doesn’t respond to Hormonal therapy
                 Endometriosis
Danazol
• Isoxazole derivative of 17 – alpha ethinyl
  testosterone
• Causes anovulation by
      • Attenuating the mid cycle surge of LH
      • Inhibiting multiple enzymes in steroidogenic pathway
      •  Testosterone levels
• Dose: 400 – 800 mg/ day for 6 months
• Adverse effects: Androgenic effects, effects on serum
  lipids,  Bone mineral density & Liver damage
                Endometriosis

Progestational drugs
• Causes endometrial decidualization & atrophy
• Medroxyprogesterone (Provera) is commonly used
• Dose: 20-30 mg/ day for 6 -9 months
• Adverse effects: Abnormal uterine bleeding, nausea,
  breast tenderness, fluid retention & depression
                Endometriosis

Gestrinone (Ethylnorgestrienone)
• Antiprogestational steroid causes  estrogen &
  progesterone receptors
• Dose: 5-10 mg/ wk - dly or twice a wk or 3 times a wk, for
  6-9 months
• Adverse effects: deepening of voice, hirsuitism &
  Clitorial hypertrophy
               Endometriosis

Combined pills
• Well tolerated & can be continued for long term
• 1 pill/ day either continuously or cyclically
• Continuous regimen is superior in patients with
  dysmenorrhea
• Adverse effects: weight gain, abnormal bleeding & HTN
                  Endometriosis
GnRH agonists
•  FSH & LH & results in endometrial atrophy &
  amenorrhea
• Intranasally or SC or IM with a frequency of twice dly to
  once in 3 months up to 3 - 6 months
• Adverse effects: transient vaginal bleeding, hot flushes,
  vaginal dryness,  libido, breast tenderness, insomnia,
  depression, irritability, fatigue, headache, osteoporosis,    
  elasticity of skin
• GnRH agonists + Add-back therapy (estrogens &
  progestogen) – less side-effects but with same efficacy, can be
  continued beyond 6 months
               Endometriosis
Hormonal Treatment

 The choice between the COCPs, Progestogens,
 Danazol & GnRH agonists depends principally
 upon their side-effect profiles because they
 relieve pain associated with endometriosis
 equally well
                      - Clinical Green Top Guidelines, 2000
                Endometriosis
Surgical management

• Conservative – Excision, Cauterization & Evaporation
• Surgeries for pain - Uterosacral Nerve Ablation
  (LUNA), Presacral Neurectomy
• Radical surgeries - Hysterectomy +/- BSO
• Surgeries for Endometrioma – Cystectomy,
  Drainage & coagulation, Fenestration
                       Endometriosis
Surgical management
Laparotomy Vs Laparoscopy




•   Efficacy is same
•   Laparoscopy – less cost & shorter recovery time even in women with advanced
    endometriosis
                   Endometriosis
Laparoscopic management

1. Excision
2. Vaporization
3. Fulguration & Desiccation
4. Cystectomy for endomterioma
5. Drainage & Coagulation for endometrioma
6. Fenestration for endometrioma
• No RCTs available to compare these procedures
• Cystectomy offer better results than drainage & coagulation for
  Endometrioma
• If no cyst wall is present, Fenestration followed by GnRH agonists
  may prove beneficial
               Endometriosis
Laparoscopic management
Surgical management




   • outcome was poorest in minimal endometriosis
   • much better in moderate & severe cases
                             - Sutton CJ et al, Fertil Steril 1994
                Endometriosis
Combination of Hormonal & Surgical
• Postoperative Danazol & Medroxyprogesterone for 6
  months lowered the pain scores significantly
                             – Telimaa S et al, Gynecol Endo, 1987
• Postoperative GnRH agonist for 6 months lowered the
  recurrence rates but with no change in pain scores
                                   – Parazzini F et al, AJOG, 1994
• Sufficient data is not available to conclude that
  hormonal & surgical combination is associated with
  significant benefits. The possible benefits should be
  weighed in the context of the adverse effects & costs
  of these therapies
                                      - Cochrane review, May 2004
              Endometriosis
Infertility Management

• No role for medical therapy with hormonal
  drugs
• Laparoscopic ablation of minimal – mild
  endometriosis may improve fertility rates
                               - Cochrane review, 2004
                     Endometriosis
IUI

• The presence of endometriosis
  does not generally impair the
  results of IUI
• Ovarian hyperstimulation using
  Gonadotrophins with IUI is better
  than no treatment or IUI alone
              -     Nulsen Jc et al, Obst Gyn, 1993 &
          -       Tummon IS et al, Fertil Steril, 1997
                          Endometriosis
    Treatment                    Pelvic pain &
                                  suspected
                                Endometriosis


 Continue
drug therapy    Success       NSAID or OCP

                                    Failure

 Continue                  Empirical GnRH agonist +              Operative
               Success                                Failure
Drug therapy                     Estro & Prog                   Laparoscopy
                              add-back therapy

                                                           GnRH agonist +
                                                             Estro & Prog
                                                           add-back therapy
                 Endometriosis
 Treatment
                             Infertility &
                       Suspected endometriosis



                  Operative Laparoscopy



                                                             Assisted
Pregnancy    Success       Watchful waiting      Failure
                                                           Reproduction
             Endometriosis
Conclusion

• Endometriosis is a mystery tour as it requires
  decision making at every stage by the physician
  and the patient.
• Endometriosis still stand as one of the most-
  investigated disorders in gynecology. So is one
  of the highest priorities for research.
Thank you

								
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