Transcript ENDOMETRIOSIS AND MANAGEMENT OPTIONS

ENDOMETRIOSIS AND
MANAGEMENT
OPTIONS
INTRODUCTION
• ENDOMTRIOSIS IS ONE OF THE COMMONEST
DISEASE ENTITIES CONFRONTING
GYNAECOLOGISTS.
• IT IS THOUGHT TO AFFECT 8-10% OF WOMEN IN
THE REPRODUCTIVE AGE GROUP
• 20-50% OF WOMEN WHO UNDERGO
LAPAROSCOPY FOR PELVIC PAIN OR INFERTILITY
WILL BE DIAGNOSED WITH ENDOMETRIOSIS
• I T IS STILL HOWEVER A FAIRLY UNKNOWN
ILLNESS OFTEN TAKING A LONG TIME BEFORE IT
IS DIAGNOSED.
INTRODUCTION CONT’D
• THERE CAN BE A DELAY OF BETWEEN 7-10 YEARS
BETWEEN ONSET OF SYMPTOMS AND
DIAGNOSIS.
• THE ASSOCIATED SYMPTOMS CAN IMPACT ON
GENERAL PHYSICAL, MENTAL AND SOCIAL
WELLBEING.
• APPARENTLY INCREASING INCIDENCE MAY BE AS
A RESULT OF INCREASED AWARENESS,
AVAILABILITY OF LAPAROSCOPY AND RECENT
RECOGNITION OF SUBTLE LESIONS.
DEFINITION
• THE PRESENCE AND PROLIFERATION OF
FUNCTIONAL ENDOMETRIAL GLANDS AND
STROMA OUTSIDE THE UTERINE CAVITY,
WHICH INDUCES A CHRONIC INFLAMMATORY
REACTION.
CLASSIFICATION
• SEVERAL SYSTEMS EXIST TO CLASSIFY
ENDOMETRIOSIS.
• THE COMMONEST IS THAT FROM THE AMERICAN
SOCIETY FOR REPRODUCTIVE MEDICINE.(ASRM).
• IN THIS, POINTS ARE ALLOCATED FOR ENDOMETRIOTIC LESIONS, -PERIOVARIAN
ADHESIONS,AND – POUCH OF DOUGLAS
OBLITERATION. THE TOTAL SCORE IS USED TO
DESCRIBE THE DISEASE AS
CLASSIFICATION CONTD
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MINIMAL
OR STAGE 1
MILD
OR STAGE 2
MODERATE OR STAGE 3
SEVERE
OR STAGE 4
THIS SYSTEM WAS DEVELOPED TO ASSIST IN
PROGNOSIS AND MANAGEMENT OF PATIENTS
UNDERGOING TREATMENT FOR SUBFERTILITY,
AND DOES NOT CORRELATE WELL WITH
SYMPTOMS ……
CLASSIFICATION CONTD
• BECAUSE ONLY VISIBLE LESIONS ARE GRADED,
DEEPLY INFILTRARING ENDOMETRIOSIS, A
MAJOR CAUSE OF PELVIC PAIN AND
DYSPAREUNIA IS TYPICALLY ASSIGNED A LOW
SCORE.
• A BETTER METHOD IS THEREFORE CLEARLY
REQUIRED.
AETIOLOGY
• DISEASE OF THEORIES.
• NONE OF THE THEORIES SATISFACTORILY
EXPLAINS ALL ASPECTS OF THE DISEASE.
• IT MAY ACTUALLY BE THAT ENDOMETRIOSIS IS
A HETEROGENOUS DISEASE WITH DIFFERENT
TYPES RESULTING FROM DIFFERENT
AETIOLOGIES.
AETIOLOGY CONTD
• RETROGRADE MENSTRUATION
(SAMPSON1927)
• MENSTRUAL EFFLUENT CONTAINING VIABLE
CELLS IS TRANSPORTED INTO THE PERITONEAL
CAVITY ALONG THE FALLOPIAN TUBES AND
IMPLANTS ON THE SURFACE OF THE
PERITONEUM. IT MAY EXPLAIN PERITONEAL
ENDOMETRIOSIS. IT HOWEVER DOES NOT
EXPLAIN WHY THOUGH RETROGRADE
MENSTRUATION IS COMMON, THE DISEASE
OCCURS IN = 10%
AETIOLOGY CONTD
• THE AMOUNT OF MENSTRUAL EFFLUENT
(OBSTRUCTED OUTFLOW ASSOCIATED WITH
MULLERIAN ANOMALIES AND SHORTER MENSTRUAL
CYCLES WITH INCREASED DURATION OF BLEEDING)
• DEFECTS IN IMMUNOLOGICAL MECHANISMS
RESPONSIBLE FOR CLEARANCE OF MENSTRUAL
EFFLUENT FROM PERITONEAL CAVITY MAY EXPLAIN
THE DIFFERENT SUSCEPTIBILITY. WOMEN WITH
ENDOMETRIOSIS HAVE A HIGHER INCIDENCE OF
AUTOIMMUNE DISEASES LIKE RHEUMATOID ARTHRITIS
AND SYSTEMIC LUPUS ERYTHEMATOSUS.
AETIOLOGY CONTD
• COELOMIC-METAPLASIA THEORY
ENDOMETRIOTIC LESIONS DEVELOP WHEN
COELOMIC MESOTHELIAL CELLS OF THE
PERITONEUM UNDERGO METAPLASIA.
• MAY EXPLAIN ENDOMETRIOMAS AND DEEPLY
INFILTRATING ENDOMETRIOSIS (DIE).
AETIOLOGY CONTD
• ENDOMETRIOMAS HAVE FEATURES IN COMMON
WITH NEOPLASIA SUCH AS CLONAL
PROLIFERATION AND MANY ARE ASSOCIATED
WITH SUBTYPES OF OVARIAN MALIGNANCY SUCH
AS ENDOMETRIOID AND CLEAR CELL
CARCINOMA.
• ENDOMETRIOMAS HAVE HOWEVER ALSO BEEN
SUGGESTED TO DEVELOP WHEN SUPERFICIAL
LESIONS ON OVARIAN CORTEX BECOME
INVERTED AND INVAGINATED
AETIOLOGY CONTD
• DEEPLY INFILTRATING ENDOMETRIOSIS HAS
BEEN DESCRIBED AS A FORM OF
ADENOMYOSIS ARISING IN MULLERIAN RESTS
IN THE RECTOVAGINAL SEPTUM.
• ANOTHER THEORY POSTULATES THE
CIRCULATION AND IMPLANTATION OF
ECTOPIC MENSTRUAL TISSUE VIA THE VENOUS
OR THE LYMPHATIC SYSTEM, OR BOTH.
TYPES OF LESIONS
• PERITONEAL ENDOMETRIOSIS
• TYPICAL
• SUPERFICIAL “POWDER-BURN” OR “GUNSHOT”
LESIONS ON PERITONEAL SURFACES AND
OVARIES>>>>BLACK, BLUE , DARK BROWN.
• ATYPICAL
• RED(PETECHIAL,VESICULAR,POLYPOID,HAEMORR
HAGIC, FLAME-LIKE), YELLOW-BROWN
PERITONEAL DISCOLOURATION, SEROUS OR
CLEAR, WHITE PLAQUES.
TYPES OF LESIONS
• ENDOMETRIOMAS
• THESE CONTAIN THICK FLUID’ LIKE TAR. THEY MAY BE
DENSELY ADHERENT TO PERITONEUM OF OVARIAN
FOSSA AND SURROUNDING FIBROSIS MAY INVOLVE
TUBES AND BOWEL.
• DEEPLY INFILTRATING ENDOMETRIOSIS (DIE)
• NODULAR DISEASE WHICH MAY EXTEND BEYOND 5MM
BENEATH THE PERITONEUM. MAY INVOLVE
UTEROSACRAL LIGAMENTS, VAGINA, BOWEL, BLADDER
OR UTERUS. TYPE AND SEVERITY OF SYMPTOMS IS
RELATED TO DEPTH OF INFILTRATION .
RISK FACTORS
• AGE
• INCREASED PERIPHERAL BODY FAT
• GREATER EXPOSURE TO
MENSTRUATION(EARLY MENARCHE, SHORT
CYCLES, LONG DURATION OF
FLOW,NULLIPARITY OR LOW PARITY,
REPRODUCTIVE TRACT ANOMALIES).
• SUBFERTILITY OR PROLONGED INTERVALS
BETWEEN PREGNANCIES.
RISK FACTORS CONTD
• GENETIC PREDISPOSITION (IT OCCURS 6-9 TIMES
MORE IN FIRST DEGREE RELATIVES OF AFFECTED
WOMEN THAN IN CONTROLS)
• IT MAY BE INHERITED AS A COMPLEX GENETIC
TRAIT LIKE ASTHMA OR DIABETES(PHENOTYPE
EMERGING ONLY IN THE PRESENCE OF
ENVIRONMENTAL RISK FACTORS).
• STUDIES HAVE SHOWN A SIGNIFICANT
SUSCEPTIBILTY LOCUS FOR ENDOMETRIOSIS ON
CHROMOSOME 10q26 AND ANOTHER ON
CHROMOSOME 20p13.
PROTECTIVE FACTORS
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SMOKING.
EXERCISE.
ORAL CONTRACEPTIVE USE.
LONG OR IRREGULAR CYCLES.
INCREASED PARITY.
SYMPTOMS
• SEVERE DYSMENORRHEA
• DEEP DYSPAREUNIA
• CHRONIC PELVIC PAIN (NON CYCLICAL ABDOMINAL
AND PELVIC PAIN OF AT LEAST 6MONTHS DURATION)
• OVULATION PAIN
• CYCLICAL PERIMENSTRUAL SYMPTOMS…BOWEL
RELATED(DYSCHEZIA, HAEMATOCHEZIA)…BLADDER
RELATED(DYSURIA, HAEMATURIA)
• LOWER BACK OR ABDOMINAL DISCOMFORT
• CHRONIC FATIGUE
SYMPTOMS CONTD
• THE PREDICTIVE VALUE OF ANY ONE SYMPTOM OR SET
OF SYMPTOMS IS UNCERTAIN SINCE EACH CAN HAVE
OTHER CAUSES.
• MANY WOMEN ARE ASYMPTOMATIC
• WHERE AS THERE IS LITTLE CORRELATION BETWEEN
DISEASE STAGE,NATURE AND SEVERITY OF SYMPTOMS,
ENDOMETRIOMAS AND DIE ARE CLEARLY ASSOCIATED
WITH SEVERE PAIN. TYPICAL PERITONEAL LESIONS
PROBABLY CAUSE PAIN AS SYMPTOMS ARE RELIEVED
BY SURGERY. IT IS UNCLEAR IF THIS APPLIES TO SUBTLE
LESIONS.
SIGNS
• PELVIC TENDERNESS
• A FIXED RETROVERTED UTERUS
• TENDER/ NODULAR UTEROSACRAL
LIGAMENTS (POSTERIOR FORNIX/POD)
• ENLARGED OVARIES (ADNEXEAL MASSES)
DIAGNOSIS
HISTORY
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DETAILED PAIN AND GYNAE HISTORY
-EXPLORE OTHER CAUSES OF PAIN
-AGE AT MENARCHE
-CYCLE FREQUENCY AND REGULARITY
-PREVIOUS PREGNANCIES
-USE OF COCPS AND HORMONAL TX
-FAMILY HX OF ENDOMETRIOSIS AND
GYNAECOLOGICAL CANCERS.
• -REMEMBER SYMPTOMS MAY HAVE OTHER CAUSES.
EXAMINATION
• THIS IS ESSENTIAL FOR DIAGNOSIS, DETERMINE
APPROPRIATE CARE AND RULE OUT OTHER
DISORDERS. EXAMINATION DURING MENSES
INCREASES THE CHANCES OF DETECTING D I E.
• - DETERMINE SIZE, POSITION AND MOBILITY OF
UTERUS( A FIXED RETROVERTED UTERUS MAY
SUGGEST SEVERE ADHESIVE DISEASE )
• -RECTOVAGINAL EXAM…PALPATE UTEROSACRAL
LIGAMENTS ( TENDER NODULES SUGGEST D I E)
• -ADNEXIAL MASSES MAY SUGGEST OVARIAN
ENDOMETRIOMAS
INVESTIGATIONS
• -ULTRASOUND SCAN..TVUSS..USELESS IN PERITONEAL
DISEASE BUT DETECTS ENDOMETRIOMAS, OVARIAN
CYSTS AND FIBROIDS. TYPICAL APPEARANCE IS THAT
OF A THICK WALLED UNILOCULAR CYST CONTAINING
LOW LEVEL ECHOES.
• -MRI..MAY BE USED IN EVALUATING EXTENT OF
DISEASE..BLADDER, RECTAL, URETERIC INVOLVEMENT.
• -CA 125.. MAY BE ELEVATED IN ENDOMETRIOSIS BUT
NOT SPECIFIC. USEFUL IN EVALUATING ADNEXIAL
MASSES(ENDOMETRIOMA)
INVESTIGATIONS CONTD
LAPAROSCOPY
• EXCEPT FOR WHEN VISIBLE DISEASE IS PRESENT
IN THE VAGINA OR ELSEWHERE, THIS IS
CONSIDERED THE GOLD STANDARD FOR
DIAGNOSTIC PURPOSES (DIRECT VISUALIZATION
OF LESIONS/ ADHESIONS).
• HISTOLOGICAL CONFIRMATION OF AT LEAST ONE
PERITONEAL LESION IS IDEAL. HISTOLOGY IS
MANDATORY IN D I E AND HELPS EXCLUDE
MALIGNANCY IN ENDOMETRIOMAS > 3CM.
INVESTIGATIONS CONTD
• THE ENTIRE PELVIS SHOULD BE EXAMINED
SYSTEMATICALLY.
• STAGE DISEASE ACCORDING TO ASRM
STAGING.
• GOOD PRACTICE- DOCUMENT IN DETAIL,
TYPE, LOCATION AND EXTENT OF ALL LESIONS
AND ADHESIONS.
• IDEAL- RECORD FINDINGS ELECTRONICALLY=
DVD, VIDEO.
DIFFERENTIAL DIAGNOSIS
UTERINE- PRIMARY DYSMENORRHEA
- ADENOMYOSIS
BOWEL - IRRITABLE BOWEL SYNDROME
-INFLAMMATORY BOWEL DISEASE
-CHRONIC CONSTIPATION
BLADDER - INTERSTITIAL CYSTITIS
-URINARY TRACT INFECTION
-URINARY TRACT CALCULI
DIFFERENTIAL DIAGNOSIS
OVARIAN
- MITTELSCHMERZ
(OVULATION PAIN)
- OVARIAN CYSTS
(TORSION, RUTURE, ETC)
FALLOPIAN TUBES - HAEMATOSALPINX
- ECTOPIC PREGNANCY
GENERAL
- NEUROPATHIC PAIN
- ADHESIONS
- PELVIC INFLAMMATORY DISEASE
TREATMENT
• MULTIPLE OPTIONS EXIST. ENDOMETRIOSIS IS
A POTENTIALLY CHRONIC PROBLEM SO
PATIENT PARTICIPATION IN DECISION MAKING
IS ESSENTIAL.
• CHOICE OF TREATMANT WILL DEPEND ON THE
AIMS FOR TREATING.
TREATMENT
AIMS
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TO IMPROVE NATURAL FERTILITY
TO ENHANCE CHANCES OF SUCCES AT ART
PAIN RELIEF AS ALTERNATIVE TO SURGERY.
PAIN RELIEF WHILE AWAITING SURGERY.
ADJUNCT TO SURGERY.
PROPHYLAXIS AGAINST DISEASE RECURRENCE.
TREATMENT:GENERAL PRINCIPLES
• FACTORS
-AGE, SEVERITY OF SYMPTOMS/ DISEASE,
DESIRE FOR PROCREATION.
• E.G 40+YRS, DEBILITATING PAIN, SEVERE
DISEASE, COMPLETED FAMILY= OFFER
TAH+BSO, PROVIDED ALL ENDOMETRIOTIC
TISSUE IS REMOVED AT THE SAME TIME.
TREATMENT:GENERAL PRINCIPLES
• YOUNG NULLIPAROUS WOMAN, WITH ABOVE
PRESENTATION WILL WANT AS MUCH TISSUE
CONSERVATION AS POSSIBLE IF SHE OPTS FOR
SURGERY.
• AGREE ON TREATMENT AIMS WITH PATIENT.
SO FOR SURGERY=INTENDED BENEFITS, RISKS
AND COMPLICATIONS SHOULD BE EXPLAINED
AND DOCUMENTED ON CONSENT FORM.
MEDICAL MANAGEMENT
• HORMONAL TREATMENTS
TRADITIONALLY HAVE ATTEMPTED TO MIMIC
PREGNANCY OR THE MENOPAUSE BASED ON
THE CLINICAL IMPRESSION THAT THE DISEASE
REGRESSES DURING THESE PHYSIOLOGICAL
STATES.
MEDICAL MANAGEMENT
• AVAILABLE OPTIONS TEND TO INDUCE
DECIDUALIZATION AND ATROPHY OF
PERITONEAL DEPOSITS BY SUPPRESSING
OVARIAN FUNCTION. PERITONEAL LESIONS
DECREASE DURING, ONLY TO REAPPEAR AFTER
THERAPY. ENDOMETRIOMAS RARELY
DECREASE IN SIZE AND ADHESIONS ARE
UNAFFECTED.
MEDICAL MANAGEMENT:PAIN
• PRIOR LAPAROSCOPY MAY NOT BE REQUIRED
BEFORE STARTING MEDICAL TREATMENT IN
WOMEN WITH SEVERE DYSMENORRHEA OR
CHRONIC PELVIC PAIN.
• IF SEVERE DYSMENORRHEA IS UNRESPONSIVE
TO NSAIDS, + PELVIC TENDERNESS,
NODULARITY OR USS DIAGNOSES AN
ENDOMETRIOMA THEN SUSPECT
ENDOMETRIOSIS.
MEDICAL MANAGEMENT:PAIN
• ALL HORMONAL TREATMENTS RELIEVE
ENDOMETRIOSIS ASSOCIATED PAIN, AND CAN
ABOLISH MENSTRUATION. TAKEN FOR SIX
MONTHS, THEIR EFFECTS ARE ALMOST EQUAL
BUT SIDE EFFECTS PROFILES AND COSTS
DIFFER.
MEDICAL MANAGEMENT:PAIN
• FIRST LINE= COCP . THERE IS SIGNIFICANT
RELIEF IN MENSES RELATED PAIN BUT NONE
IN NON MENSTRUAL PAIN(? CONTINUOUS VS
CYCLICAL).
• SECOND LINE (AFTER COCP OR
PROGESTOGENS)=GnRH AGONISTS
MEDICAL MANAGEMENT
• NSAIDS
• THERE ARE FOUR BROAD TYPES OF
HORMONE-BASED TREATMENT:
• PROGESTOGENS
• ANTIPROGESTOGENS
• THE COMBINED ORAL CONTRACEPTIVE PILL
• GONADOTROPHIN-RELEASING HORMONE
(GNRH) ANALOGUES
MEDICAL
MANAGEMENT:PROGESTOGENS
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DEPOT MEDROXY PROGESTERONE ACETATE
NORETHISTERONE
DYDROGESTERONE
LNG-IUS (MIRENA)
DIRECT EFFECT ON ENDOMETRIUM= MARKED
DECIDUALIZATION AND ATROPHY OF BOTH EUTOPIC
AND ECTOPIC ENDOMETRIUM . ALSO SUPPRESSION OF
HPO AXIS. ALSO INHIBIT ANGIOGENESIS.
• DRAW BACK=NON CYCLIC PELVIC PAIN NOT
SIGNIFICANTLY REDUCED.
MEDICAL MANAGEMENT:ANTI
PROGESTOGENS
• DANAZOL
• GESTRINONE
• ALSO ANDROGENIC. INDUCE AMENORRHEA
VIA SUPPRESSION OF HPO AXIS…INCREASED
SERUM ANDROGENS AND LOW SERUM
OESTROGEN LEVELS.
• EFFECTIVE
• DRAW BACK=WT GAIN, OEDEMA, MYALGIA,
ACNE, HIRSUITISM, BREAST ATROPHY
MEDICAL MANAGEMENT: COMBINED
ORAL CONTRACEPTIVE PILL
• RESULT IN OVULATION INHIBITION, REDUCED
MENSTRUAL FLOW AND DECIDUALIZATION OF
ENDOMETRIAL IMPLANTS.
• OESTROGEN COMPONENT MAY BE A DRAW
BACK.
• CYCLIC USE PERMITS MENSTRUATION SO
DYSMENORRHEA STILL OCCURS + POSSIBLE
RETROGRADE FLOW
MEDICAL MANAGEMENT :
GONADOTROPHIN RELEASING
HORMONE ANALOGUES
• AMONG MOST WIDELY USED MEDICAL THERAPIES.
• INDUCE MEDICAL MENOPAUSE BY DOWN REGULATING
HYP-PIT GnRH RECEPTORS>>SUPPRESS OVULATION,
DECREASE OESTROGEN LEVELS.
• DRAW BACKS=HYPOESTROGENIC S-E >>HOT FLUSHES,
VAGINAL DRYNESS, LOSS OF LIBIDO, EMOTIONAL
LABILITY, LOSS OF BONE MINERAL DENSITY.
• RECENTLY USE OF ‘ADD BACK ‘ REGIMES >>HRT TO
MAKE IT POSSIBLE TO USE TX LONG TERM.
MEDICAL MANAGEMENT:
SUBFERTILITY
• HORMONAL TREATMENT IN THE FORM OF
OVARIAN SUPPRESSION DOES NOT IMPROVE
CHANCES OF NATURAL CONCEPTION IN
MINIMAL TO MILD DISEASE. HARMFUL.
• ART: CONTROLLED OVARIAN
HYPERSTIMULATION COMBINED WITH
INTRAUTERINE INSEMINATION (IUI) IMPROVES
FERTILITY IN ENDOMETRIOSIS.
MEDICAL
MANAGEMENT:SUBFERTILITY
• IVF: PATIENTS OVER 35YEARS SHOULD BE
COUNSELLED FOR IVF. PREGNANCY RATES ARE
LOWER THAN IN WOMEN WITH OTHER
DIAGNOSES.
PATIENTS WITH CHRONIC OR ADVANCED
ENDOMETRIOSIS MAY BENEFIT FROM LONG
TERM (3-6MONTHS) TREATMENT WITH A
GnRH AGONIST BEFORE AN IVF CYCLE.
SURGERY :INDICATIONS
• PATIENTS WITH PELVIC PAIN
-WHO DO NOT RESPOND TO, DECLINE OR HAVE
CONTRA-INDICATIONS TO MEDICAL THERAPY.
-WHO HAVE AN ACUTE ADNEXIAL EVENT
-WHO HAVE SEVERE INVASIVE DISEASE
INVOLVING BOWEL, BLADDER, URETERS OR
PELVIC NERVES.
SURGERY: INDICATIONS
• PATIENTS WHO HAVE OR ARE SUSPECTED TO
HAVE AN OVARIAN ENDOMETRIOMA
-PATIENTS WITH INFERTILITY AND ASSOCIATED
FACTORS…PAIN, A PELVIC MASS.
-PATIENTS FOR WHOM AN UNCERTAINTY OF
DIAGNOSIS AFFECTS MANAGEMENT(AS WITH
CHRONIC PELVIC PAIN).
SURGERY:GOAL
• TO REMOVE ALL VISIBLE PERITONEAL LESIONS,
ENDOMETRIOMAS, D I E AND ASSOCIATED
ADHESIONS AND RESTORE NORMAL ANATOMY
AND OPTIMIZE OVARIAN AND TUBAL
PRESERVATION.
• SINCE DEPTH OF INFILTRATION IS DIFFICULT TO
JUDGE, EXCISION OR VAPORIZATION IS
PREFERABLE FOR TYPICAL LESIONS. EXCISION IS
PREFERRED FOR ENDOMETRIOMAS AS
RECURRENCE RATES ARE HIGHER FOLLOWING
MARSUPIALIZATION.
SURGERY: METHOD
• LAPAROSCOPY IS PREFERRED.
-DECREASES MORBIDITY AND DURATION OF
HOSPITALIZATION AND THEREFORE COST.
-LESS ADHESIOGENIC
-IF LOCAL EXPERTISE IS LACKING REFERRAL TO A
SPECIALIZED CENTRE WITH NECESSARY
EXPERTISE TO OFFER ALL AVAILABLE
TREATMENT IN A MULTIDISCIPLINARY
CONTEXT IS STRONGLY RECOMMENDED.
SURGERY: METHOD
• PRINCIPLES OF MICROSURGERY VIZ DILIGENT
HAEMOSTASIS, REDUCED FULGURATION ,
AVOIDANCE OF TISSUE DRYING AND LIMITED
USE OF SUTURES MAKE LAPAROSCOPY
ADVANTAGEOUS.
SURGERY:PAIN RELIEF
• ABLATION OF LESIONS IN MINIMAL TO
MODERATE DISEASE REDUCES PAIN AT 6
MONTHS. LUNA( LAPAROSCOPIC UTERINE NERVE
ABLATION) HAS NOT BEEN PROVEN TO BE
NECESSARY SINCE BY ITSELF NO EFFECT HAS BEEN
NOTED.
• IN D I E AND ENDOMETRIOMAS, STUDIES HAVE
SHOWN 80% OF WOMEN WITH SEVERE
SYMPTOMS ARE PAIN FREE FOLLOWING
SURGERY.
SURGERY
• DRUG THERAPY MAY RELIEVE INFLAMMATION
AND REDUCE PAIN IN EARLY SUPERFICIAL
DISEASE BUT CORRECTIVE SURGERY +/- DRUG
THERAPY IS PREFERABLE.
• RECTOVAGINAL, RECTAL AND UTEROSACRAL
LESIONS ALWAYS NEED SURGERY
• ENDOMETRIOMAS ALWAYS NEED SURGERY
• ABNORMAL ANATOMY AND ADHESIONS
ALWAYS NEED SURGERY
SURGERY: CO2 LASER
Classification
Pregnancies
Improved pain
I minimal
II mild
III moderate
IV severe
72%
60%
50%
44%
89%
87%
85%
80%
AFS
ENDOMETRIOSIS IN ADOLESCENTS
• 38% OF ENDOMETRIOSIS PATIENTS HAD SYMPTOMS
STARTING BEFORE THE AGE OF 15YRS=
ENDOMETRIOSIS REGISTRY, CANADA.
• ON AVERAGE TOOK 4.2 PHYSICIAN CONSULTATIONS
BEFORE DIAGNOSIS WAS REACHED.
• LESIONS IN ADOLESCENTS AT EARLY STAGE AND MAY
BE CLEAR VESICLES AND RED LESIONS.
• ENDOMETRIOSIS=MOST COMMON CAUSE OF 2*
DYSMENORRHEA IN ADOLESCENTS.
• PHYSICAL EXAMINATION WILL RARELY REVEAL
ABNORMALITIES IN ADOLESCENTS.
ENDOMETRIOSIS AND CANCER
• AS EARLY AS 1925 SAMPSON DESCRIBED
CRITERIA FOR MALIGNANCY ORIGINATING FROM
ENDOMETRIOSIS.
• THERE IS AN INCREASED OVERALL CANCER RISK
IN ENDOMETRIOSIS PATIENTS. MORE GREATLY
INCREASED OVARIAN CANCER RISK ESPECIALLY
CLEAR CELL AND ENDOMETRIOID VARIETIES.
• BIOPSY OF ENDOMETRIOSIS LESIONS SHOULD
THEREFORE BE CONSIDERED NOT ONLY TO
CONFIRM DIAGNOSIS BUT ALSO TO EXCLUDE
UNDERLYING MALIGNANCY.
TIPS
• CLINICIANS SHOULD BE AWARE OF CLINICAL FACTORS
THAT INCREASE LIKELIHOOD OF ENDOMETRIOSIS.
• PRIMARY FOCUS OF INVESTIGATION AND TREATMENT
SHOULD BE RESOLUTION OF PRESENTING SYMPTOMS.
• PELVIC PAIN THAT IS NOT PRIMARY DYSMENORRHEA
SHOULD BE CONSIDERED ENDOMETRIOSIS UNTIL
PROVEN OTHERWISE.
• DUE TO DELAY (7-12YRS) FROM SYMPTOM ONSET TO
DEFINITIVE DIAGNOSIS, ENDOMETRIOSIS SHOULD BE
CONSIDERED IN DIFFERENTIAL DIAGNOSES OF PELVIC
PAIN IN YOUNG WOMEN.
END
• THANK YOU.