Transcript Endometriosis

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
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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)
6.2 –7.9%
Population-Based Studies
Epidemiological Study
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0.25 new cases/1000
woman-years
Prevalence = 7.5%
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Endometriosis Affects ~5
Million Women, 30-40%
are Infertile
Surgical Series (Uncontrolled)
1 – 53%
Surgical Series (Controlled)
23 – 47% (Infertile)
1 – 5% (Fertile)
6.2 –7.9%
Population-Based Studies
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
3%
36 –45
15%
< 19
6%
26 –35
52%
Dr Mona Shroff
www.obgyntoday.info
19 – 25
24%
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–
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”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 ovarian steroidogenesis .
 The dose is 2.5 - 5 mg orally twice weekly .
Dr Mona Shroff
www.obgyntoday.info
Surgical Treatment
(Laparoscopy / Laparotomy)
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/
(
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