Endometriosis

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					ENDOMETRIOSIS


 Dr.Mona Shroff M.D.
 Department of Obstetrics and Gynecology
 SMIMER



                  Dr Mona Shroff    www.obgyntoday.info
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
- Pelvic
- Extra pelvic
   Umbilicus.
   Scars (Lap.).
   Lungs & plura.
   Others.
            Dr Mona Shroff   www.obgyntoday.info
 Uterine= Adenomyosis (50%).
 Extraut:
- Ovary 30%
- Pelvic peritoneum 10%.
- F. tube.
- Vagina.
-Bladder & rectum.
- Pelvic colon.
- Ligaments.


              Dr Mona Shroff   www.obgyntoday.info
Dr Mona Shroff   www.obgyntoday.info
          Prevalence

    Surgical Series (Uncontrolled)   1 – 53%

    Surgical Series (Controlled)     23 – 47% (Infertile)
                                       1 – 5% (Fertile)
    Population-Based Studies         6.2 –7.9%

    Epidemiological Study            0.25 new cases/1000
                                         woman-years
                                       Prevalence = 7.5%
                                       
                                       Endometriosis Affects ~5
                                         Million Women, 30-40%
                                         are Infertile


                                                                        Surgical Series (Uncontrolled)   1 – 53%

                                                                        Surgical Series (Controlled)     23 – 47% (Infertile)
                                                                                                           1 – 5% (Fertile)
                                                                        Population-Based Studies         6.2 –7.9%

                                                                        Epidemiological Study            0.25 new cases/1000
                                                                                                             woman-years
                                                                                                           Prevalence = 7.5%
                                                                                                           
                                                                                                           Endometriosis Affects ~5
                                                                                                             Million Women, 30-40%
                                                                                                             are Infertile
                                                                    
Age at Diagnosis

                            > 45      < 19
  36 –45                    3%        6%
   15%                                                      19 – 25
                                                              24%




                             26 –35
                              52%
           Dr Mona Shroff             www.obgyntoday.info
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
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
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
Diagnosis

 Laparoscopy (“Gold Standard)
 Laparotomy
 Inconclusive: CA-125, Pelvic Exam, History,
  Imaging Studies
 Biopsy Preferable Over Visual Inspection




            Dr Mona Shroff   www.obgyntoday.info
Appearance

Endometriosis May Appear
Brown
Black (“Powderburn”)
Clear (“Atypical”)


Endometriosis May Be Associated with
Peritoneal Windows


            Dr Mona Shroff   www.obgyntoday.info
Dr Mona Shroff   www.obgyntoday.info
Dr Mona Shroff   www.obgyntoday.info
Dr Mona Shroff   www.obgyntoday.info
   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
Treatment :
Consideration
 Age.
 Symptoms.
 Stage.
 Infertility.
           Dr Mona Shroff   www.obgyntoday.info
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
Dr Mona Shroff   www.obgyntoday.info
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
  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
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
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
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
  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
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
 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
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
   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 ovari-an steroidogenesis .
 The dose is 2.5 - 5 mg orally twice weekly .


                 Dr Mona Shroff   www.obgyntoday.info
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
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
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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posted:8/8/2011
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